Fill and Sign the Contractor Affidavit Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ___________________ Address: _____________________ City: __________________________ State: _____ Zip: _____________ Phone: _____________________ Fax: _______________________ CONTRACTOR'S FINAL PAYMENT AFFIDAVIT – CORPORATION or LLC STATE OF FLORIDA COUNTY OF ______________________ . BEFORE ME, the undersigned authority, personally appeared ___________________________ (name of affiant) who, after being first duly sworn, deposes and says of his or her personal knowledge the following: 1. He or she is the _________________________ (title of affiant) of ____________________________ (name of company) hereinafter referred to as the "Contractor." 2. Contractor, pursuant to a contract with _________________________ (name of owner), hereinafter referred to as the "Owner," has furnished or caused to be furnished labor, materials, and services for the construction of certain improvements to real property as more particularly set forth in said contract. 3. This Affidavit is executed by the Contractor in accordance with Section 713.06 of the Florida Statutes for the purposes of obtaining final payment from the Owner in the amount of $ _______________ . 4. All work to be performed under the contract has been fully completed, and all lienors Contractor’s Final Payment Affidavit Page 1 of 3 under the direct contract have been paid in full, except the following listed lienors: Name/Address of Lienor _________________________________________________________ Amount Due ____________________________ Name/Address of Lienor ________________________________________________________ Amount Due _____________________________ Signed, sealed and delivered this _____ day of __________________ , 20 ______ . By: ___________________________ Name of Affiant ______________________ Title of Affiant ______________________ Type or Print Name ______________________ Name of Company Attest: Secretary State of ______________ County of _____________ Sworn to (or affirmed) and subscribed before me this _____ day of _______________, 20____ by _________________________ (name of affiant) who is personally known to me or produced _________________________ as identification, and did take an oath. ________________________________ NOTARY PUBLIC Printed Name of Notary _________________________ My Commission Expires: _________________________ Contractor’s Final Payment Affidavit Page 2 of 3 Certificate of Service I, _____________________________________, hereby certify that I have delivered this day a true and attested copy of the foregoing to ___________________________________ by: ( ) Actual Delivery to the person to be served. ( ) Mailing a true and correct copy of same by registered or certified U.S. mail, with postage prepaid, or by overnight or second-day delivery with evidence of delivery. ( ) If service cannot be made by the above methods, by posting on the premises. ________________________ Signature Contractor’s Final Payment Affidavit Page 3 of 3