Fill and Sign the Azng State Tuition Reimbursement and W 9 Az Dema Form

Affidavit Acknowledging Payment in Full Page 1 of 3Prepared by, recording requested by and return to:Name ________________________Company __________________________Address __________________________City __________________________State ______________Zip _____________Phone ____________________------------------------------------Above this line for Official Use Only ----------------------------------- AFFIDAVIT ACKNOWLEDGING PAYMENT IN FULL - INDIVIDUAL STATE OF GEORGIA COUNTY OF __________________ The undersigned mechanic and/or materialman has been employed by ___________________________________ (name of contractor) to furnish__________________________________ (describe materials and/or labor) for the construction of improvements known as __________________________________ (title of the project or building) which is located in the City of _________________________, County of _____________________, and is owned by __________________________ (name of owner) and more particularly described as follows: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. [Full Legal Description- DESCRIBE THE PROPERTY UPON WHICH THE IMPROVEMENTS WERE MADE BY USING EITHER A METES AND BOUNDS DESCRIPTION, THE LAND LOT DISTRICT, BLOCK AND LOT NUMBER, OR STREET ADDRESS OF THE PROJECT.] Pursuant to O.C.G.A. Section 44-14-366 the undersigned executed a lien waiver and release with respect to this property dated _______ day of ____________________, _____. The amount set forth in said waiver and release($_______________) was received on _____ day of ________________, ______, and the undersigned hereby gives notice of such payment in full. Upon recordation of this affidavit in the county in which the Affidavit of Nonpayment was recorded, the Affidavit of Nonpayment to which it relates shall be deemed void. The above facts are sworn true and correct by the undersigned, this _____ day of ___________________, ______. ____________________(SEAL) Claimant's Signature Print or Type Name: ________________ Affidavit Acknowledging Payment in Full Page 2 of 3 Affidavit of Service State of ________________County of ____________________I, ________________________________, hereby certify that I have this date sent a true and correct copy of this ______________________________________ by certified mail, return receipt requested, registered mail, return receipt requested, statutory overnight delivery, acknowledging delivery signed by addressee or agent of addressee requested, in accordance with law, to the owner of the property and the contractor, as the agent of the owner, which the names and addresses are as follows: __________________________________ __________________________________ ____________________________________________________________________ DATED this the ______ day of __________________, 20______. _____________________________Signature _____________________________ Type or Print Name Sworn to and executed in the presence of:_____________________WitnessSworn to (or affirmed) and subscribed before me this ____ day of __________ (month), __________ (year), by _______________________ (name of person making statement)._______ Personally Known_______ Produced IdentificationType and # of ID __________________________ ____________________________(Signature of Notary) (Seal) _____________________________ (Name of Notary Typed, Stamped or Printed) Affidavit Acknowledging Payment in Full Page 3 of 3 Notary Public, State of GeorgiaMy Commission Expires: ______________