Fill and Sign the Interim Affidavit Form

After Recording Return to: ________________________ ________________________ ________________________ ________________________ ) ) ) ) ) ) ) ) -------- Above This Line Reserved For Official Use Only---------------- CONTRACTOR'S INTERIM PAYMENT AFFIDAVIT – INDIVIDUAL STATE OF FLORIDA COUNTY OF ______________________ . BEFORE ME, the undersigned authority, personally appeared ___________________________ (name of affiant) who, after being first duly sworn, deposes and says of his or her personal knowledge the following: 1. He or she is the _________________________ (title of affiant) of ____________________________ (name of contractor’s business) hereinafter referred to as the "Contractor." 2. Contractor, pursuant to a contract with _________________________ (name of owner), hereinafter referred to as the "Owner," has furnished or caused to be furnished labor, materials, and services for the construction of certain improvements to real property as more particularly set forth in said contract. 3. This Affidavit is executed by the Contractor in accordance with Section 713.06 of the Florida Statutes for the purposes of obtaining payment from the Owner in the amount of $ _______________ . 4. All of the work to be performed under the contract has been fully completed, and all lienors under the direct contract have been paid in full, except the following described work and listed lienors: Work still to be performed under contract: ___________________________________________ . Name/Address of Lienor _________________________________________________________ Amount Due ____________________________ Name/Address of Lienor ________________________________________________________ Amount Due _____________________________ Contractor’s Interim Payment Affidavit Page 1 of 2 Signed, sealed and delivered this _____ day of __________________ , 20 ______ . By: ___________________________ Name of Affiant _____ __________________________ Title of Affiant _____ __________________________ Type or Print Name _____ __________________________ Name of Contractor’s Business 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 _________________________ Certificate of Service I, _____________________________________, hereby certify that I have delivered this day a true and attested copy of the foregoing to ___________________________________ by: ( ) Actual Delivery to the person to be served. ( ) Mailing a true and correct copy of same by registered or certified U.S. mail, with postage prepaid, or by overnight or second-day delivery with evidence of delivery. ( ) If service cannot be made by the above methods, by posting on the premises. ________________________ Signature Contractor’s Interim Payment Affidavit Page 2 of 2