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Fill and Sign the Florida Sworn Statement 497302839 Form

Fill and Sign the Florida Sworn Statement 497302839 Form

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SWORN STATEMENT OF ACCOUNT FROM LIENOR TO CONTRACTOR- INDIVIDUAL TO: _________________________ DATE: _____________________ ____________________________________________ ____________________________________________ (contractor's name and address) In accordance with Section 713.16(4), Florida Statutes, and in response to your demand for a statement of account in your letter dated ___________________ , 20 _____ , the undersigned submits the following Statement of Account: Nature of labor or services performed, if any: _____________________________________________________________________________ . Nature of labor or services to be performed, if any: _____________________________________________________________________________ . Materials furnished: __________________________________________________________ . Materials to be furnished, if known: _____________________________________________ . Amount paid to date: $ _____________________ Amount due: $ _____________________ Amount to become due, if known: $ _______________________ Amount of our contract: $ ______________________ Names of Parties to the contract: _________________________________________________________________________ . The undersigned certifies that this Statement of Account has been served at the address specified above, on ____________________ , 20 ______ , in accordance with Section 713.18, Florida Statutes. Sworn Statement of Account from Lienor to Contractor Page 1 of 2 Lienor’s Name _____ ____________________ By (signature) _________________________ Type or Print Name _____ ___________________ STATE OF ___________ COUNTY OF _____________ Sworn to (or affirmed) and subscribed before me this _____ day of _________________, 20______ by _________________________ (name of person making statement) who is personally known to me or produced _________________________ as identification, and who did take an oath. ____________________________ NOTARY PUBLIC Printed Name of Notary _________________________ Commission Expires _________________________ Sworn Statement of Account from Lienor to Contractor Page 2 of 2

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