Fill and Sign the Ga Affidavit Form 481379449

Affidavit of Nonpayment Page 1 of 3 After Recording Return to: AFFIDAVIT OF NONPAYMENT PURSUANT O.C.G.A. SECTION 44 -14 -366 [CORPORATION ] STATE OF GEORGIA COUNTY OF __________________ THE UNDERSIGNED MECHANIC AND/OR MATERIALMAN HAS BEEN EMPLOYED BY ___________________________________ (NAME OF CONTRACTOR) TO FURNISH __________________________________ (DESCRIBE M ATERIALS AND/OR LABOR) FOR THE CONSTRUCTION OF IMPROVEMENTS KNOWN AS __________________________________ (TITLE OF THE PROJECT OR BUILDING) WHICH IS LOCATED IN THE CITY OF _________________________ , COUNTY OF _____________________ , AND IS OWNED BY __________________________ (NAME OF OWNER) AND MORE PARTICULARLY DESCRIBED AS FOLLOWS: [FULL LEGAL DESCRIPTION - DESCRIBE THE PROPERTY UPON WHICH THE IMPROVEMENTS WERE MADE BY USING EITHER A METES AND BOUNDS DESCRIPTION, THE LAND LOT DISTRICT, BLOCK AND LOT NUMBER, OR STREET ADDRESS OF THE PROJECT.] PURSUANT TO O.C.G.A. SECTION 44 -14 -366 THE UNDERSIGNED EXECUTED A LIEN WAIVER AND RELEASE WITH RESPECT TO THIS PROPERTY DATED _______ DAY OF ____________________ , _____ . THE AMOUNT SET FORTH IN SAID WAIVER AND RELEASE($ _______________ ) HAS NOT BEEN PAID, AND THE UNDERSIGNED HEREBY GIVES NOTICE OF SUCH NONPAYMENT. THE ABOVE FACTS ARE SWORN TRUE AND CORRECT BY THE UNDERSIGNED, THIS _____ DAY OF ___________________ , ______ . Affidavit of Nonpayment Page 2 of 3 (SEAL) Claimant's Signature Print or Type Name Title Name of Corporation: Attest: Secretary WITHIN SEVEN DAYS OF FILING THIS AFFIDAVIT OF NONPAYMENT, THE FILING PARTY SHALL SEND A COPY OF THE AFFIDAVIT BY REGISTERED OR CERTIFIED MAIL OR STATUTORY OVERNIGHT DELIVERY TO THE OWNER OF THE PROPERTY. IF THE FILING PARTY IS NOT IN PRIVITY OF CONTRACT WITH THE PROPERTY OWNER AND A NOTICE OF COMMENCEMENT IS FILED FOR THE IMPROVEMENT ON THE PROPERTY FOR WHICH THE FILING PARTY' S LABOR, SERVICES, OR MATERIALS WERE FURNISHED, A COPY OF THE AFFIDAVIT SHALL BE SENT TO THE CONTRACTOR AT THE ADDRESS SHOWN ON THE NOTICE OF COMMENCEMENT. WHENEVER THE OWNER OF THE PROPERTY IS AN ENTITY ON FILE WITH THE SECRETARY OF STATE'S CORPORATIONS D IVISION, SENDING A COPY OF THE LIEN TO THE COMPANY'S ADDRESS OR THE REGISTERED AGENT'S ADDRESS ON FILE WITH THE SECRETARY OF STATE SHALL BE DEEMED SUFFICIENT. Affidavit of Service State of ________________ County of ____________________ I, ________________________________ , hereby certify that I have this date sent a true and correct copy of this ___________________ ___________________ by certified mail, return receipt requested, registered mail, return receipt requested, statutory overnight delivery, acknowledging delivery signed by addressee or agent of addressee requested, in accordance with law, to the owner of the property and the contractor, as the agen t of the owner, which the names and addresses are as follows: DATED this the ______ day of __________________ , 20 ______ . Affidavit of Nonpayment Page 3 of 3 _____________________________ Signature _____ ________________________ Type or Print Name Sworn to and executed in the presence of: (Witness) Type or Print Name Str eet Address City, State and Zip State of Georgia County of ____________ This instrument acknowledged before me this ______ day of ____________ , 20 ______ , by ______________________________ . Personally Known Produced Identification Type and No. of ID: ______________________________ Signature of Notary (SEAL) (Name of Notary Typed, Stamped or Printed) Notary Public, State of Georgia