Fill and Sign the Connecticut Affidavit of Original Contractor by Individual Form

Affidavit of Original Contractor Page 1 of 2 Prepared by, recording requested by and return to: ---------------------- Above this Line for Official Use Only --------------------- Name: ____________________ Company: _____________________ Address: ______________________ City: _______________________ State: _____ Zip: _________ Phone: _____________________ _ Fax: ______________________ AFFIDAVIT OF ORIGINAL CONTRACTOR – INDIVIDUAL (Conn. Gen. Stat. § 49 -35) BEFORE ME, the undersigned authority, on this day personally appeared _________________________________ , ("AFFIANT") w ho is personally known to me (or, if not being personally known to me, did confirm his/her identity presenting ___________________________________ as identification (i.e. drivers license #), and appearing to be fully competent and of sufficient age, upon being du ly sworn, stated upon Affiant's oath the following: 1. The undersigned, _______________________________ , is an original contractor, who may be served with process at the following address _______________________________________________________________________ , and is responsible for the construction, raising, removal, or repairing of a building, or development of a lot or plot of land, and would state as follows: 2. The undersigned began working under a contract for the constructi on, raising, removal, or repairing of the building, or development of the lot or plot of land described as _______________________________________________________________ _________ ________________________________________________________________________ on or about t he _____ day of __________________ , 20 _____ . 3. Pursuant to Conn. Gen. Stat. § 49 -35, the undersigned has recorded this affidavit not later than fifteen (15) days after commencing work, and is therefore entitled to be furnished a copy of any notice of intent to file a lien provided against the above -described property. This the _____ day of _________________ , 20 _____ . ________________________ Affiant _____ ___________________ Type or Print Name Affidavit of Original Contractor Page 2 of 2 Acknowledgement State of Connecticut County of __________________ On this the ____________ day of _____________________, ____________, before me, ________________________ (name of notary), personally appeared ____________________________________, known to me (or satisfactorily proven) to be the person(s) whose name(s) __ _______ ( is or are) subscribed to the within instrument and acknowledged that ________________________ (he/she/they) executed the same for the purposes therein contained. In witness whereof I hereunto set my hand. Date:___________________________ ______________________________ Notary Public Print Name: ___________________ My Commission Expires: ____________________