Fill and Sign the Affidavit Payment Form

AFFIDAVIT OF PAYMENT OF SUBCONTRACTORS, MATERIALMEN, ETC. BY SUBCONTRACTOR -CORPORATION STATE OF TEXAS 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       ____________________ of       , a Corporation and makes this Affidavit in his or her capacity as such. 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 subcontractor and as a condition of final payment certifies that all subcontractors, laborers, or materialmen of the undersigned have been paid in full for all labor and materials used in the construction of the project, except as follows (List unpaid persons): Name       Address Phone                   Name       Address Phone                   Name       Address Phone                   Name       Address Phone                   Name       Address Phone             Affidavit of Payment of Subcontractor Page 1 of 3       Name       Address Phone                   NOTICE: A PERSON, INCLUDING A SELLER, COMMITS AN OFFENSE IF THE PERSON INTENTIONALLY, KNOWINGLY, OR RECKLESSLY MAKES A FALSE OR MISLEADING STATEMENT IN THIS AFFIDAVIT. SUCH AN OFFENSE IS A MISDEMEANOR. A PERSON ADJUDGED GUILTY OF SUCH AN OFFENSE SHALL BE PUNISHED BY A FINE NOT TO EXCEED $4,000 OR CONFINEMENT IN JAIL FOR A TERM NOT TO EXCEED ONE YEAR OR BOTH A FINE AND CONFINEMENT. A PERSON MAY NOT RECEIVE COMMUNITY SUPERVISION FOR THE OFFENSE. A PERSON SIGNING THIS AFFIDAVIT IS PERSONALLY LIABLE FOR ANY LOSS OR DAMAGE RESULTING FROM ANY FALSE OR INCORRECT INFORMATION IN THE AFFIDAVIT. FURTHER AFFIANT SAYETH NOT. Dated this the _____ day of _________________ , 20 ____ . ______________________________________________________ Name of Corporation Signature:       Print Name:       Title:       Doing Business as:       SWORN TO AND SUBSCRIBED before me on this the _____ day of ______________ , 20 ____ by _________________________________ , as __________________________ of _______________________________ , a __________________________ Corporation. Notary Public       Printed Name My Commission Expires:       Affidavit of Payment of Subcontractor Page 2 of 3 TX Code § 53.259 Affidavit of Payment of Subcontractor Page 3 of 3