Fill and Sign the Fl Statement 497302836 Form

REQUEST FOR SWORN STATEMENT OF ACCOUNT BY CONTRACTOR- CORPORATION WARNING: YOUR FAILURE TO FURNISH THE REQUESTED STATEMENT, SIGNED UNDER OATH, WITHIN 30 DAYS, OR THE FURNISHING OF A FALSE OR FRAUDULENT STATEMENT WILL DEPRIVE YOU OF YOUR RIGHTS UNDER THE PAYMENT BOND FURNISHED BY CONTRACTOR. TO: ____________________________________ ________________________________________ ________________________________________ (name and address of lienor) The undersigned hereby demands a written statement under oath of his or her account showing the nature of the labor or services performed and to be performed, if any, the materials furnished, the materials to be furnished, if known, the amount paid on account to date, the amount due, and the amount to become due, if known, as of the date of the statement by the lienor, for the improvement of real property identified as: (property description) ______________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________________________________ . DATED ON _____ , day of ________________ , 20 _____ . _______________________ (signature of corporate contractor) _____ __________________ Type or Print Name _____ ___________________ Title _____ ____________________ Name of Corporation Address: ___________________________ _______________________ (date of request) Request for Sworn Statement of Account Page 1 of 1