Fill and Sign the Notice of Payment Individual Ohio Form

NOTICE OF PAYMENT- INDIVIDUAL (Ohio Revised Code Section 1311.011(B)(8)(a)) State of Ohio County of ____________________ ________________________________ , whose address is _____________________________________________________________________ , being first duly sworn, states: 1. That pursuant to Ohio Revised Code §1311.011(B)(8) the owner, part-owner, or lessee, or lending institution has withheld payment from original contractor, _________________________________ , as a result of a dispute over payments due to subcontractor, material supplier, or laborer, _________________________________ . 2. That the subcontractor, material supplier, or laborer, would hereby give notice pursuant to Ohio Revised Code §1311.011(B)(8)(a) that the amount of money claimed by him to be due has been paid. 3. Further, that there being no further dispute regarding payment between this subcontractor, material supplier, or laborer and the original contractor, that any amount withheld by the owner, part-owner, lessee, or lending institution may be paid to the original contractor without further delay. THIS the _____ day of _______________ , 20 ______ . By: ___________________________________ Type or Print Name: _____ _________________ Witness: __________________________________ Witness: __________________________________ Notice of Payment – Individual Page 1 of 2 Acknowledgment of Individual STATE OF OHIO COUNTY OF _____________________ The foregoing instrument was acknowledged before me this _____________________ (date) by _________________________________________ (name of person acknowledged.) ______________________________ Notary Public Printed Name: _________________ My Commission Expires: _____________________ ACKNOWLEDGED, SWORN TO AND SUBSCRIBED before me on this the _______ day of _____________________, _________. ____________________________________ Notary Public My Commission Expires: ________________ This Instrument was prepared by:                         Signature       Print or Type Name Notice of Payment – Individual Page 2 of 2