Fill and Sign the Affidavit Payment 497328419 Form

After Recording Return to:                                           ) ) ) ) ) ) ) ) -------- Above This Line Reserved For Official Use Only---------------- CONTRACT FOR:       CONTRACT DATE:       PROJECT:       CONTRACTOR'S FINAL AFFIDAVIT OF PAYMENT TO SUBCONTRACTORS STATE OF       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. He is the _________________________(title) of ______________________(name of business) hereinafter referred to as "Contractor." 2. At all times material hereto, Contractor has been doing business in _______________ County, State of __________________ . 3. This Affidavit is made for the purpose of acknowledging and payment to the Contractor for work done and materials supplied on real property described as: (property description) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. That all subcontractors engaged by the Contractor to perform or provide labor, services and/or materials under the contract between Contractor and the owner of the above- described property have been paid in full, except as follows: Name/Address       Amount Due       - 1 - Name/Address       Amount Due       Name/Address       Amount Due       FURTHER AFFIANT SAYETH NOT. CONTRACTOR       By       Address:             STATE OF _______________ COUNTY OF _____________ PERSONALLY came and appeared before me, the undersigned authority in and for the jurisdiction aforesaid, the within named __________________________________________ , who acknowledged to me that he signed, executed and delivered the foregoing Contractor’s Final Affidavit of Payment to Subcontractors on the day and year therein mentioned. GIVEN under my hand and official seal of office, this the ____ day of _________ , 20 __ . ________________________________ NOTARY PUBLIC My Commission Expires: ______________ - 2 -