Fill and Sign the Payment Subcontractor Form

AFFIDAVIT OF PAYMENT OF SUBCONTRACTORS, MATERIALMEN, ETC. BY SUBCONTRACTOR -INDIVIDUAL STATE OF TEXAS COUNTY OF       BEFORE ME, the undersigned authority, duly authorized to administer oaths and take acknowledgments, personally appeared       who being duly sworn, deposes and says: 1. The undersigned is the subcontractor on the project identified below. This affidavit concerns the following project: Project Name or Address:       Owner name and Address:             Short Legal Description ("Real Property"):                   2. This Affidavit is made for the purpose of acknowledging, and the undersigned states on oath, that the undersigned is the subcontractor and as a condition of final payment certifies that all subcontractors, laborers, or materialmen of the undersigned have been paid in full for all labor and materials used in the construction of the project, except as follows (List unpaid persons): Name       Address Phone                   Name       Address Phone                   Name       Address Phone                   Name       Address Phone                   Name       Address Phone                   Affidavit of Payment of Subcontractors Page 1 of 2 Name       Address Phone                   NOTICE: A PERSON, INCLUDING A SELLER, COMMITS AN OFFENSE IF THE PERSON INTENTIONALLY, KNOWINGLY, OR RECKLESSLY MAKES A FALSE OR MISLEADING STATEMENT IN THIS AFFIDAVIT. SUCH AN OFFENSE IS A MISDEMEANOR. A PERSON ADJUDGED GUILTY OF SUCH AN OFFENSE SHALL BE PUNISHED BY A FINE NOT TO EXCEED $4,000 OR CONFINEMENT IN JAIL FOR A TERM NOT TO EXCEED ONE YEAR OR BOTH A FINE AND CONFINEMENT. A PERSON MAY NOT RECEIVE COMMUNITY SUPERVISION FOR THE OFFENSE. A PERSON SIGNING THIS AFFIDAVIT IS PERSONALLY LIABLE FOR ANY LOSS OR DAMAGE RESULTING FROM ANY FALSE OR INCORRECT INFORMATION IN THE AFFIDAVIT. FURTHER AFFIANT SAYETH NOT. Dated this the _____ day of _________________ , 20 ____ . Signature: Print Name:       Doing Business as:       SWORN TO AND SUBSCRIBED before me on this the _____ day of ______________ , 20 ___ by       . Notary Public       Printed Name My Commission Expires:       TX Code § 53.259 Affidavit of Payment of Subcontractors Page 2 of 2