Fill and Sign the Chapter 219 Sales and Use Taxes Form

Account and Affidavit of Accounts Page 1 of 3STATE OF ARKANSAS ) ) ss. COUNTY OF _____________________ ) ACCOUNT AND AFFIDAVIT OF ACCOUNTS MATERIALMAN OR LABOR LIENS Comes now ______________________________, a duly authorized corporation, limited liability company or other registered business entityby and through _____________________, its _____________________, states on oath:1.That ______________________________ sold or delivered to ______________________________________ services as an architect and consultant for the design of an office building known as ________________________ and located at __________________________, ___________, ________________ County, Arkansas. The statement of account is attached hereto as Exhibit “A” and incorporated herein. The finally delivery of services has occurred within the last 120 days. 2. The attached statement of account is true and correct, and that there is now duly owing to ________________________, after all credits, the sum of $____________.3. That said services will furnished for and used in the design for the construction of an office building located ________________________, ____________, ___________ County, Arkansas which was constructed or to be constructed on the following described real property in _____________ County, Arkansas, to wit:SEE ATTACHED SURVEYOR’S DESCRIPTION. 4.That __________________, claims a lien on the property described aforesaid the Account and Affidavit of Accounts Page 2 of 3 secure the sum of $______________ plus all accrued interest, fees and costs; and that more than ten (10) days caused notice to be served, copy of which is attached hereto. Respectfully Submitted, __________________________________Name of CorporationBy: _______________________________________ Signature Title __________________________________Type or Print Name ATTEST:_________________________________________ Secretary Account and Affidavit of Accounts Page 3 of 3 VERIFICATION State of ____________________ County of ____________________On this _________ day of ____________________, 20________, before me, __________________________________, a Notary Public, (or before any officer within this State or without the State now qualified under existing law to take acknowledgments), duly commissioned, qualified and acting, within and for said County and State, appeared in person the within named ___________________________________and ___________________________________, (being the person or persons authorized by said corporation, [business trust, estate, partnership, limited liability company, association, joint venture, or other legal entity] to execute such instrument, stating their respective capacities in that behalf), to me personally well known (or satisfactorily proven to be such person), who stated that _________ [he, she, or they] was [were] the ___________________________________[and _________] of the ___________________________________, a corporation, [business trust, estate, partnership, limited liability company, association, joint venture, or other legal entity], and was [were] duly authorized in __________[his, her, or their] respective capacity [capacities] to execute the foregoing instrument(s) for and in the name and behalf of said corporation, [business trust, estate, partnership, limited liability company, association, joint venture or other legal entity], and further stated and acknowledged that[he, she, or they] had so signed, executed, and delivered said foregoing instrument for the consideration, uses, and purposes therein mentioned and set forth.IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal this _________ day of ___________________________________, 20_________. _____________________________________________(Notary Seal)(Notary Public)