Fill and Sign the Il Verified Form

CONTRACTOR'S AFFIDAVIT - INDIVIDUAL STATE OF ILLINOIS COUNTY OF __________________ The undersigned, upon being duly sworn, states that he/she is the contractor for the __________________________________ work on the building located at ______________________________________________________ owned by __________________________________ . That the total amount of the contract including extras is $ _________________ on which he/she has received payment of $ ________________ prior to this payment. That the following are the names of all parties who have furnished material or labor, or both, for said work, and the amount due or to become due to each. Name Address Labor/Material Supplied Contract Amount Amount Paid Amount Payment Due Balance _____________ _____________ _____________ _____________________ ________ ________ _______ ______ _____________ _____________ _____________ _____________________ ________ ________ _______ ______ _____________ _____________ _____________ _____________________ ________ ________ _______ ______ _____________ _____________ _____________ _____________________ ________ ________ _______ ______ _____________ _____________ _____________ _____________________ ________ ________ _______ ______ _____________ _____________ _____________ _____________________ ________ ________ _______ ______ _____________ _____________ _____________ _____________________ ________ ________ _______ ______ Signed this _____ day of ______________ , 20 _____ . __________________________________ Contractor _____ _____________________________ Type or Print Name Contractor’s Affidavit – Individual Page 1 of 2 State of _________________ County of_________________ Signed and sworn (or affirmed) to before me on ________________ (date) by ______________ (name/s of person/s making statement). _________________________________ Signature of Notary Public (SEAL) (770 ILCS 60/5) It shall be the duty of the contractor to give the owner, and the duty of the owner to require of the contractor, before the owner or his agent, architect, or superintendent shall pay or cause to be paid to the contractor or to his order any moneys or other consideration due or to become due to the contractor, or make or cause to be made to the contractor any advancement of any moneys or any other consideration, a statement in writing, under oath or verified by affidavit, of the names and addresses of all parties furnishing materials and labor and of the amounts due or to become due to each. Merchants and dealers in materials only shall not be required to make statements. Contractor’s Affidavit – Individual Page 2 of 2