Lien Submission Form

Use this form below so we can start your lien today! Once completed, one of our representatives will contact you.

Note: if you have already submitted this form and just need to make a payment to us, please visit our payment options.

By submitting this form, I hereby certify under penalty of perjury that the information entered by me on this document is true and correct and I have no information or belief that there is a valid defense to the claims which give rise to the lien(s). I have verified the below vehicle for correct valuation, license plate and vehicle identification numbers. Independent Lien Service will assume no responsibility for illegible or missing information. I appoint Independent Lien Service as Power of Attorney and authorize Independent Lien Service or its employees to sign on my behalf for the purpose of a lien sale on the below vehicle.

Company Information Company Name: Address: City: Zipcode: (5 digits) State: Daytime Phone: Email:

Vehicle/Vessel Information Customer/Owner of Vehicle: Customer Address: Customer City: Customer Zipcode: (5 digits) Customer State:

Is the Vehicle/Vessel in your possession? Yes No

Date of Possession: Date of Repair Completion: (if applicable) License Plate or CF Number: License State: Make: Model: Year: VIN or Hull Number: Motorcycle Engine Number: (if applicable) Repair Shop Bar Number: (required if charging repairs) Repair Amount: Daily Storage Charge:

Vehicle Value: Under $4000 Over $4000

Vessel Value: Under $1500 Over $1500

Other Information How did you hear about us? Comments: Please enter your full name for authorization of this lien sale submission. This will act as your signature.

Note: The Yellow boxes are required fields and must be completed.
If you have already submitted this form and just need to make a payment to us, please visit our payment options.

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Thank You,
The Independent Lien Service Department

Independent Lien Service
415-706-6344 voice line
707-774-6469 fax line