Fill and Sign the Ohio Release Form

AFFIDAVIT OF ORIGINAL CONTRACTOR REQUESTING RELEASE OF FUNDS BY LENDING INSTITUTION - INDIVIDUAL (Ohio Revised Code Section 1311.011(B)(4)) State of Ohio County of _______________ ________________________________ , whose address is ____________________________________________________________________________ , being first duly sworn, states: 1. Notice is hereby given that ___________________________________ [Contractor] has paid in full all subcontractors, material suppliers, and laborers, for all labor, work performed, and materials supplied prior to the date of purchase or during and prior to the payment period, excepting: (A) Claimant: _______________________________ Amount Claimed: ___________________________________ (B) Claimant: ___________________________________ Amount Claimed: ________________________________ (C) Claimant: ___________________________________ Amount Claimed: ________________________________ (D) Claimant: __________________________________ Amount Claimed: _________________________________ 2. Further, that no other claims exist other than claims identified above. THIS the _____ day of ______________ , 20 ______ . By: ___________________________________ Affidavit of Original Contractor Page 1 of 3 Type or Print Name: _____ ________________ Witness: __________________________________ Witness: __________________________________ 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       Affidavit of Original Contractor Page 2 of 3 Print or Type Name Affidavit of Original Contractor Page 3 of 3