Fill and Sign the Affidavits State Bar of Michigan Form

Sworn Statement Page 1 of 3 SWORN STATEMENT --CORPORATION State of Michigan ) ) County of _______________ ) ________________________________ , as representative of ________________________________ a(n) ________________________________ corporation, being duly sworn, states the following : __________________________________ is the (contractor) (subcontractor) for an improvement to the following real property in ___________________________________ County, Michigan, described as follows: [Insert Legal Description] ______________________________________________________________ _____________________________________________________________ ___________ _______________________________________________________________________ . The following is a statement of each subcontractor , supplier and laborer, for wh om payment of wages or fringe benefits and withholdings is due but unpaid, with whom the (contractor) (subcontractor) has (contracted) (subcontracted) for perfor mance under the con tract with the owner or lessee , and the amounts due to the persons as of the date of this statement are correctly and fully set forth opposite their names : Name , Address and Phone Number of Subcontractor, Supplier, or Laborer Type of Improvement Furnished Total Contract Price Amount Already Paid Amount Currently Owing Balance to Complete (optional) Amount of Laborer Wages Due but Unpaid Amount of Laborer Fringe Benefits and Withholdings Due but Unpaid ________________________________________________________________________ ________________________________________________________________________ _________________________________ _______________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _____ ___________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________ ________________________ ________________________________________________________________________ ________________________________________________________________________ Totals: _________________________________________________________________ (Some columns may not be applicable to all persons listed) Sworn Statement Page 2 of 3 The contractor has not procured material from, or subcontracted with, any person other than those set forth and owes no money for the impr ovemen t other than the sums set forth . * I make this statement as the (contractor) (subcontractor) or as _________________________ ________ of the (contractor) (subcontractor) t o represent to the owner or lessee of the property and his or her agents that the property is free from claims of construction liens, or th e possibility of construction liens, except as specifically set forth in this statement and except for claims of construction liens by laborers that may be provided under S ection 109 of the Construction Lien Act, 1980 PA 497 , MCL 570.1109 WARNING TO OWNER OR LESSEE : AN OWNER OR LESSEE OF THE PROPERTY MAY NOT RELY ON THIS SWORN STATEMENT TO AVOID THE CLAIM OF A SUBCONTRACTOR, SUPPLIER, OR LABORER WHO HAS PROVIDED A NOTICE OF FURNISHING OR A LABORER WHO MAY PROVIDE A NOTICE OF FURNISHING UNDER S ECTION 109 OF THE CONSTRUCTION LIEN ACT , 1980 PA 497, MCL 570.1109 TO THE DESIGNEE OR TO THE OWNER OR LESSEE IF THE DESIGNEE IS NOT NAMED OR HAS DIED. IF THIS SWORN STATEMENT IS IN REGARD TO A RESIDENTIAL STRUCTURE, ON RECEIPT OF THIS SWORN STATEMENT, THE OWNER OR LESSEE, OR THE OWNER’S OR LESSEE’S DESIGNEE MUST GIVE NOTICE OF ITS RECEIPT, EITHER IN WRITING, OR BY TELEPHONE, OR PERSONALLY, TO EACH SUBCONTRACTOR, SUPPLIER, AND LABORER WHO HAS PROVIDED A NOTICE OF FURNISHING UNDER SECTION 109 OR, IF A NOTICE OF FUR NISHING IS EXCUSED UNDER SECTION 108 OR 108A, TO EACH SUBCONTRACTOR, SUPPLIER, AND LABORER NAMED IN THE SWORN STATEMENT. IF A SUBCONTRACTOR, SUPPLIER WHO HAS PROVIDED A NOTICE OF FURNISHING OR WHO IS NAMED IN THE SWORN STATEMENT MAKES A REQUEST, THE OWNER, LESSEE, OR DESIGNEE S HALL PROVIDE THE REQUESTER A COPY OF THE SWORN STATEMENT WITHIN 10 BUSINESS DAYS AFTER RECEIVING THE REQUEST. ________________________ Deponent _____ ___________________ Type or Print Name _____ ___________________ Title _____ ___________________ Corporation Sworn Statement Page 3 of 3 WARNING TO DEPONDENT: A PERSON WHO GIVES A FALSE SWORN STATEMENT WITH INTENT TO DEFRAUD IS SUBJECT TO CRIMINAL PENALTIES AS PROVIDED IN SECTION 110 OF THE CONSTRUCTION LIEN ACT, 1980 PA 497, MCL 570.1110. Subscribed and sworn to by _______________________ before me on the ___ day of 20____ . Signature: ______________ ___________________ Printed Name: _____________________________ Notary public, State of Michigan, County of __ __ My commission expires______________________ *Materials furnished by a contractor or a subcontractor out of his or her own inventory, and which has not been purchased specifically for the purpose of performing the contract, need not be listed.