Fill and Sign the Affidavit of Work Authorization Brentwood Mo Form

Affidavit of Contractor Certifying Subcontractors Have Been Paid Page 1 of 2 AFFIDAVIT OF CONTRACTOR CERTIFYING SUBCONTRACTORS HAVE BEEN PAID STATE OF MISSOURI COUNTY OF _________________________________ BEFORE ME, the undersigned authority, duly authorized to administer oaths and take acknowledgments, personally appeared ________________________________ who being duly sworn, deposes and says: 1. The undersigned is the original contractor on the project identified below. This affidavit concerns the following project: Project Name or Address:_____________________________________________ Owner name and Address: ___________________________________________ ___________________________________________ ___________________________________________ Short Legal Description ("Real Property"): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2. This Affidavit is made for the purpose of acknowledging, and the undersigned states on oath, that the undersigned is the original contractor and as a condition of final payment certifies that all subcontractors, laborers, or materialmen of the undersigned have be paid in full for all labor and materials used in the construction of the project, except as follows (List unpaid persons): Address Phone ______________________________ Name ______________________ ______________________________ _______________ Address Phone ______________________________ Name ______________________ ______________________________ _______________ Address Phone ______________________________ Name ______________________ ______________________________ _______________ Address Phone ______________________________ Name ______________________ ______________________________ _______________ Address Phone ______________________________ Name ______________________ ______________________________ _______________ Address Phone Name ______________________ ______________________________ _______________ Affidavit of Contractor Certifying Subcontractors Have Been Paid Page 2 of 2 ______________________________ FURTHER AFFIANT SAYETH NOT. Dated this the _____ day of _________________, 20____. Signature: Print Name: Doing Business as: STATE OF MISSOURI COUNTY OF ______________ Subscribed and affirmed before me this _____ day of ______________, 20___ by ___________________________________. Notary Public Printed Name My Commission Expires: