Form H-100A "Artificer's Lien" - Connecticut

What Is Form H-100A?

This is a legal form that was released by the Connecticut Department of Motor Vehicles - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2018;
  • The latest edition provided by the Connecticut Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form H-100A by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

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Download Form H-100A "Artificer's Lien" - Connecticut

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ARTIFICER'S LIEN
H-100A Rev. 2-2018
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
60 STATE STREET, WETHERSFIELD, CT 06161-5520
DEALERS AND REPAIRERS SECTION
On The Web At: ct.gov/dmv
INSTRUCTIONS
1.
Print clearly or type.
2.
Complete the entire form.
3.
Date and sign the notification at the bottom of the form and submit to the address above.
4.
Enclose a fee of $10.00. Make check or money order payable to "DMV". The $10.00 fee is
required to file an ARTIFICER'S LIEN.
5.
Submit a copy of the repair invoice ("repair/work order") (no estimates).
ARTIFICER'S LIEN - $10.00 Fee Required
Complete this form if you claim a lien on a motor vehicle in your custody upon which you have completed authorized work
that is properly recorded on an invoice and if there is no application pending to dissolve the lien within 30 days after completion
of the work. Enclose fee of $10.00.
NAME OF DEALER/REPAIRER AND PHONE NUMBER
DATE VEHICLE LEFT AT DEALER/REPAIRER
DEALER/
REPAIRER
ADDRESS OF DEALER/REPAIRER
DEALER/REPAIRER LICENSE NUMBER
INFORMATION
NAME OF LIENHOLDER(S)
LIENHOLDER
INFORMATION
ADDRESS OF LIENHOLDER(S)
YEAR
MAKE
MODEL
ODOMETER READING
VEHICLE IDENTIFICATION NUMBER (or chassis number)
COLOR
NUMBER OF CYLINDERS
VEHICLE
INFORMATION
BODY STYLE
FUEL TYPE
MARKER PLATE NUMBER (If plate is on vehicle)
STATE
DATE OF COMPLETION OF WORK ON VEHICLE
OWNER OF VEHICLE OR PERSON WHO AUTHORIZED WORK
AMOUNT OF LIEN CLAIMED
$
NAME OF OWNER(S)
OWNER
INFORMATION
ADDRESS OF OWNER(S)
COMMENTS
The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, the undersigned, under penalty of false statement, in
accordance with the provisions of Sections 14-110 and 53a-157b of the Connecticut General Statutes. I understand that if I make a statement which I
do not believe to be true with the intent to mislead the Commissioner, I will be subject to prosecution under the above-cited laws.
AUTHORIZED SIGNATURE
DATE SIGNED
X
ARTIFICER'S LIEN
H-100A Rev. 2-2018
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
60 STATE STREET, WETHERSFIELD, CT 06161-5520
DEALERS AND REPAIRERS SECTION
On The Web At: ct.gov/dmv
INSTRUCTIONS
1.
Print clearly or type.
2.
Complete the entire form.
3.
Date and sign the notification at the bottom of the form and submit to the address above.
4.
Enclose a fee of $10.00. Make check or money order payable to "DMV". The $10.00 fee is
required to file an ARTIFICER'S LIEN.
5.
Submit a copy of the repair invoice ("repair/work order") (no estimates).
ARTIFICER'S LIEN - $10.00 Fee Required
Complete this form if you claim a lien on a motor vehicle in your custody upon which you have completed authorized work
that is properly recorded on an invoice and if there is no application pending to dissolve the lien within 30 days after completion
of the work. Enclose fee of $10.00.
NAME OF DEALER/REPAIRER AND PHONE NUMBER
DATE VEHICLE LEFT AT DEALER/REPAIRER
DEALER/
REPAIRER
ADDRESS OF DEALER/REPAIRER
DEALER/REPAIRER LICENSE NUMBER
INFORMATION
NAME OF LIENHOLDER(S)
LIENHOLDER
INFORMATION
ADDRESS OF LIENHOLDER(S)
YEAR
MAKE
MODEL
ODOMETER READING
VEHICLE IDENTIFICATION NUMBER (or chassis number)
COLOR
NUMBER OF CYLINDERS
VEHICLE
INFORMATION
BODY STYLE
FUEL TYPE
MARKER PLATE NUMBER (If plate is on vehicle)
STATE
DATE OF COMPLETION OF WORK ON VEHICLE
OWNER OF VEHICLE OR PERSON WHO AUTHORIZED WORK
AMOUNT OF LIEN CLAIMED
$
NAME OF OWNER(S)
OWNER
INFORMATION
ADDRESS OF OWNER(S)
COMMENTS
The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, the undersigned, under penalty of false statement, in
accordance with the provisions of Sections 14-110 and 53a-157b of the Connecticut General Statutes. I understand that if I make a statement which I
do not believe to be true with the intent to mislead the Commissioner, I will be subject to prosecution under the above-cited laws.
AUTHORIZED SIGNATURE
DATE SIGNED
X