Fill and Sign the Acknowledging Payment Form

Prepared by, recording requested by and return to: Name ________________________ Company __________________________ Address __________________________ City __________________________ State ______________ Zip _____________ Phone ____________________ ------------------------------------Above this line for Official Use Only ----------------------------------- AFFIDAVIT ACKNOWLEDGING PAYMENT IN FULL - CORPORATION STATE OF GEORGIA COUNTY OF __________________ The undersigned mechanic and/or materialman has been employed by ___________________________________ (name of contractor) to furnish __________________________________ (describe materials and/or labor) for the construction of improvements known as __________________________________ (title of the project or building) which is located in the City of _________________________ , County of _____________________ , and is owned by __________________________ (name of owner) and more particularly described as follows: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . [Full Legal Description- DESCRIBE THE PROPERTY UPON WHICH THE IMPROVEMENTS WERE MADE BY USING EITHER A METES AND BOUNDS DESCRIPTION, THE LAND LOT DISTRICT, BLOCK AND LOT NUMBER, OR STREET ADDRESS OF THE PROJECT.] Pursuant to O.C.G.A. Section 44-14-366 the undersigned executed a lien waiver and release with respect to this property dated _______ day of ____________________ , _____ . The amount set forth in said waiver and release($ _______________ ) was received on _____ day of ________________ , ______ , and the undersigned hereby gives notice of such payment in full. Upon recordation of this affidavit in the county in which the Affidavit of Nonpayment was recorded, the Affidavit of Nonpayment to which it relates shall be deemed void. The above facts are sworn true and correct by the undersigned, this _____ day of ___________________ , ______ . ____________________(SEAL) Claimant's Signature Print or Type Name: _____ ___________ Title _____ _____________________ Affidavit Acknowledging Payment in Full Page 1 of 3 Name of Corporation: _______________ Attest: Secretary Affidavit of Service State of ________________ County of ____________________ I, ________________________________ , hereby certify that I have this date sent a true and correct copy of this ______________________________________ by certified mail, return receipt requested, registered mail, return receipt requested, statutory overnight delivery, acknowledging delivery signed by addressee or agent of addressee requested, in accordance with law, to the owner of the property and the contractor, as the agent of the owner, which the names and addresses are as follows: __________________________________ __________________________________ __________________________________ __________________________________ DATED this the ______ day of __________________ , 20 ______ . _____________________________ Signature _____ ________________________ Type or Print Name Sworn to and executed in the presence of: _____________________ Witness Sworn to (or affirmed) and subscribed before me this ____ day of __________ (month), __________ (year), by _______________________ (name of person making statement). _______ Personally Known _______ Produced Identification Type and # of ID __________________________ Affidavit Acknowledging Payment in Full Page 2 of 3 ____________________________ (Signature of Notary) (Seal) _____________________________ (Name of Notary Typed, Stamped or Printed) Notary Public, State of Georgia My Commission Expires: ______________ Affidavit Acknowledging Payment in Full Page 3 of 3