Fill and Sign the Ia Corporation 497304873 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: Company: Address: City: State: Zip: Phone: Fax: Parcel Identification Number: Legal Description: VERIFIED STATEMENT OF ACCOUNT—CORPORATION (Iowa Code Ann. §572.8) COMES NOW, ____________________________, as a representative of _____________________ a _____________________ corporation which has furnished labor or materials for the improvement of property described as ____________________ _______________________________________________________________________, and would state as follows: 1. The undersigned began furnishing labor and/or materials to the above-described property on the ____ day of ___________, 20___, and completed furnishing the same on the ____ day of ______________, 20___. 2. The name and last known mailing address of the owner, agent, or trustee of the property is ______________________________________________________________. Verified Statement of Account Page 1 of 3 3. An accounting of the material furnished or labor performed: Material Furnished/Labor Performed Date(s) Amount Due ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. The total amount due the undersigned, allowing for all credits is $ ____________. 5. If the undersigned is not a contractor or subcontractor, the undersigned hereby certifies that a notice containing the name, mailing address, and telephone number of the undersigned, along with the name of the subcontractor to whom labor and/or materials was furnished, was provided to the principal contractor within thirty (30) days of the first furnishing of labor and/or materials, and is attached hereto. This the ______ day of _______________________, 20____. ______________________________ Signature ______________________________ Title ______________________________ Corporation I, _______________________________, do hereby swear or affirm that the matters alleged and things contained in the above Verified Statement of Account are true and correct to the best of my knowledge, information, and belief. ________________________ Affiant STATE OF IOWA COUNTY OF _________________ On this ____________ day of ______________________, ______________, before me, a Notary Public, in and for said county, personally appeared ________________________________________, to me personally known, who being Verified Statement of Account Page 2 of 3 by me duly (sworn or affirmed) did say that that person is _________________________________________ (Insert title of executing officer) of said ______________________________________ (corporation or association) and that said instrument was signed on behalf of the said ____________________________________ (corporation or association) by authority of its board of ______________________________ (directors or trustees) and the said __________________________ acknowledged the execution of said instrument to be the voluntary act and deed of said _____________________________________________ (corporation or association) by it voluntarily executed. ______________________________ Notary Public My Commission Expires: ____________________ (SEAL) IA § 572.8 Verified Statement of Account Page 3 of 3