Fill and Sign the 43 133 an Affidavit or a Signed Statement of Payment Form

Affidavit of Payment Prior to Sale or Refinance Page 1 of 1 Affidavit of Payment Prior to Sale or Refinance – Individual (Va. Code Ann. § 43-13.3) State of Virginia County (or city) of ________________, to wit: I, ____________________________________ (notary or other officer) for the county (or city) aforesaid, do certify that, ___________________________________ owner or ___________________________________ agent for owner of the property located at and described as _______________________________________________________________________________________________________________________________________________, this day made oath before me in my county (or city) aforesaid that: 1. The undersigned is the owner of a one-or two-family residential dwelling unit.2. ( ) All persons performing labor or furnishing materials in connection with the improvements on such property within one hundred twenty (120) days prior to the date of settlement and with whom such owner is in privity of contract have been paid in full, or ( ) The name, address and amount payable or claimed to be payable to any person so performing labor or furnishing materials and with whom such owner is in privity of contract is ______________________________________________________________________________________________________________________________________________________________________________________________________________________. ____________________________________ Signature of Owner ____________________________________ Type or Print Name Given under my hand this the _____ day of _______________ 20______. ________________________________ (Notary Public or Magistrate, et cetera.)