Fill and Sign the Affidavit Payment Contractor Form

AFFIDAVIT OF PAYMENT BY CLAIMANT OTHER THAN CONTRACTOR--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 ______________________________ (title) of _____________________________ , a Corporation and makes this affidavit in such capacity being duly authorized to do so by the corporation. 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 has furnished labor or materials for the construction of improvements on real property and as a condition of payment for such labor or materials, the undersigned certifies that all subcontractors, laborers, or materialmen of the undersigned have be paid in full for all labor and materials provided to the undersigned, except as follows (List unpaid persons): Name Address             Phone             Amount Due       Name Address             Phone       Affidavit of Payment Page 1 of 4       Amount Due       Affidavit of Payment Page 2 of 4 Name Address             Phone             Amount Due       3. [Optional] The affiant hereby waives and releases all lien rights under the laws of the State of Texas relating to the material, services and labor described above conditioned upon payment of the above amount claimed. 4. [Optional] The affiant hereby agrees that, from the funds to be paid as described above, affiant will pay the following claimants in the following amounts: Amount Claimant (name, address and phone)                                                                                                 5. [Optional] The undersigned indemnifies you for any loss or expense resulting from false or incorrect information in the affidavit. 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 Claimant:       Officer Title:       Print Name:       Doing Business As:       Affidavit of Payment Page 3 of 4 SWORN TO AND SUBSCRIBED before me on this the _____ day of ______________ , 20 ____ by _________________________________ , as __________________________ of _______________________________ , a __________________________ Corporation. Notary Public       Printed Name My Commission Expires:       TX Code § 53.085 Affidavit of Payment Page 4 of 4