General Authorization Letter (Page 2 of 2) in pdf

General Authorization Letter Page 2

*** BEFORE WE WILL SEND A LETTER ***

EACH ITEM MUST BE COMPLETELY FILLED IN AND THIS FORM SIGNED

NAME:

INTAKE #:

ADDRESS:

MEMBERSHIP #:

PHONE #:

FAX:

E-MAIL:

Please issue a letter to the below named individual or business based upon the information provided below:

1. Full Name of Opposing Party:

2. Opposing Party's Complete Address including zip code (if a business, we require full name if Opposing

Party Representative and/or Owner):

3. A brief & legible description of the facts that give rise to the need for this letter (please give dates and

details of the occurrence, use separate sheet of paper if necessary):

4. The demand that you wish for us to make on the Opposing Party (NOTE: if this is a demand for

damages, please specify the TOTAL amount and how it was computed; principal, interest, repairs, costs

of completion, etc.):

Signature:

Date:

This GAL does not apply to enforcing lien rights, since specific time frames and procedures may apply. If specific lien rights

you want to enforce, you must contact this office to discuss how to protect and enforce your lien, or you may lose your rights.

Please attach photocopies of any supporting documents up to 10 pages, i.e., contract, prior letters, invoices.

(DO NOT SEND YOUR ORIGINALS.)

G YES

G NO

Please send DRAFT for my review before mailing final.

G Fax

G U.S. Mail

G E-mail

Please select your preference:

R ev. 08/24/12

General Authorization Letter Page 2