Fill and Sign the Request for Release of Funds Corporation or Llc Ohio Form

AFFIDAVIT OF CORPORATION AS ORIGINAL CONTRACTOR REQUESTING RELEASE OF FUNDS BY LENDING INSTUTION (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 ___________________________________ as President of ________________________________ , a _________________________________ corporation, whose address is ___________________________________________________________________ , ___________________ , Ohio _______________ , [ 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. Affidavit of Corporation Page 1 of 3 THIS the _____ day of _______________ , 20 ______ . By: ___________________________________ Type or Print Name: _____ ______________________________ Witness: __________________________________ Witness: __________________________________ Attest: Secretary This instrument was prepared by __________________ (name). STATE OF OHIO COUNTY OF _____________________ The foregoing instrument was acknowledged before me this _____________________ (date) by __________________________________________ (name of officer or agent, title of Affidavit of Corporation Page 2 of 3 officer or agent) of __________________________________________ (name of corporation acknowledging) a __________________________________________ (state or place of incorporation) corporation, on behalf of the corporation. 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 Affidavit of Corporation Page 3 of 3