Debris Removal Affidavit Form

DEBRIS REMOVAL AFFIDAVIT

This Debris Removal Affidavit (the "Affidavit") is executed on by Contractor Name: License Number: with principal address: , and Property Owner Name: for the property located at: .

RECITALS

WHEREAS, on or about a storm, incident, or other event generated debris located at the property described above; and

WHEREAS, Contractor represents that Contractor is duly licensed, equipped, and able to remove, transport, and dispose of such debris in accordance with applicable laws and permits; and

WHEREAS, the parties desire to document the nature, quantity, origin, disposition, and legal compliance associated with the removal of debris from the Property and to provide a sworn certification for record, reimbursement, and indemnity purposes.

NOW, THEREFORE

In consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Affidavit: "Debris" means accumulated vegetative matter, construction or demolition material, personal property, appliances, household goods, and other solid waste generated by the incident identified above; "Removal" means collection, loading, transportation and lawful disposal or recycling; "Disposal Facility" means the licensed facility receiving the debris.

2. SCOPE OF WORK

Contractor shall remove debris from the Property as described in the attached itemization and shall transport and dispose of debris at licensed disposal facilities in compliance with all applicable local, state, and federal laws. Contractor's specific operations, methods, and working hours shall be at Contractor's discretion so long as they comply with law and do not unreasonably interfere with Property Owner's use of the Property.

3. AFFIDAVIT AND CERTIFICATION

Contractor hereby certifies, under penalty of perjury, the following facts are true and correct to the best of Contractor's knowledge:

(a) Origin of Debris: The debris removed originated from the Property described above and was generated as a direct result of the incident identified above. Origin description:

(b) Quantity and Measurement: The total estimated quantity of debris removed is cubic yards (or equivalent weight) and the method of measurement:

(c) Disposal Facility and Manifests: Debris was transported to located at . Attached manifest or ticket numbers:

(d) Hazardous Materials: Contractor affirms that, to the best of Contractor's knowledge, the debris removed: Contains hazardous materials? Yes No If yes, describe handling and disposition:

(e) Removal Period: Debris was removed during the period beginning and ending .

4. REPRESENTATIONS, WARRANTIES AND COMPLIANCE

Contractor represents and warrants that Contractor performed the removal, transportation, and disposal in compliance with all applicable laws, regulations and required permits, including but not limited to environmental, solid waste, and transportation laws. Contractor shall obtain and maintain all required permits and provide copies of permits, manifests, and disposal receipts upon request.

5. INDEMNITY

Contractor agrees to indemnify, defend and hold harmless Property Owner, its officers, agents, and employees from and against any and all claims, liabilities, losses, damages, fines, penalties, costs and expenses (including reasonable attorneys' fees) arising from or related to Contractor's performance of the debris removal operations, except to the extent caused by Property Owner's gross negligence or willful misconduct.

6. INSURANCE

Contractor shall maintain commercial general liability, automobile liability and workers' compensation insurance in amounts customary for the work and in compliance with law. Evidence of insurance, including carrier and policy numbers, is provided below.

7. RECORDS, RECEIPTS AND INVOICES

Contractor shall furnish Property Owner, and any funding or regulatory authority upon lawful request, copies of all manifests, disposal receipts, weight tickets, invoices, and any other records reasonably necessary to verify compliance and quantities removed. Contractor certifies that all such records are true and accurate.

8. PAYMENT; LIEN WAIVER

Upon receipt of payment in full for the work described and for the sum stated on any accompanying invoice, Contractor shall execute and deliver to Property Owner a conditional or unconditional waiver of lien (as applicable) for the indicated work. Payment terms and amounts:

9. NOTICES

All notices, requests, consents and other communications required or permitted under this Affidavit must be in writing and delivered to the addresses set forth below (or to such different address as a party may designate by notice).

10. MISCELLANEOUS PROVISIONS

Governing Law: This Affidavit shall be governed by and construed in accordance with the laws of the state in which the Property is located, without regard to conflict of laws principles.

Entire Agreement: This Affidavit, together with attachments and exhibits identified herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior agreements and understandings, whether written or oral.

Severability: If any provision of this Affidavit is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Amendments; Waiver; Counterparts: No amendment shall be effective unless in writing signed by both parties. No waiver shall be effective unless in writing signed by the waiving party. This Affidavit may be executed in counterparts and by electronic signature, each of which shall be deemed an original.

11. ACKNOWLEDGMENT

The undersigned Contractor affirms under penalty of perjury under the laws of the governing jurisdiction that the facts set forth in this Affidavit are true and correct.

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