Fill and Sign the Statement of Account Individual South Dakota Form

Sworn Statement of Account – Individual (S.D. Codified Laws Ann. §44-9-10) State of South Dakota County of ____________________ COMES NOW, __________________________________ , as a party who has furnished labor and/or materials for the improvement of the property located at and described as ________________________________________________________________________ ____________________________________________________________________ , and would provide notice of the following: 1. The undersigned began to provide labor and/or materials for the above-described property on the ______ day of __________________ , 20 ______ . 2. The following labor and/or materials were furnished on the following dates: labor/materials date cost/value _____________________________________________________________ ___________ __________________________________________________ ______________________ _______________________________________ _________________________________ ____________________________ ____________________________________________ _________________ _______________________________________________________ ______ _____________________________________________________________ _____ ________________________________________________________ ________________ _____________________________________________ ___________________________ __________________________________ . 3. The undersigned would hereby provide notice that the undersigned is entitled to a lien for the value of the above listed labor and/or materials, against the above described property, in the amount of $ ______________ . 4. Further, pursuant to South Dakota Codified Laws Ann. § 44-9-10, the undersigned would hereby provide notice to the owner of the above described property that upon receipt of this notice, the property owner shall withhold from the project’s contractor so much of the contract price as may be necessary to meet the claims of the undersigned. This the _____ day of ________________ , 20 _______ . _________________________ Signature ______ ___________________ Type or Print Name Sworn Statement of Account Page 1 of 2 STATE OF SOUTH DAKOTA COUNTY OF _________________ Subscribed and sworn to before me on this the ______ day of ______________ , 20 ______ , by said affiant. ______________________________ Notary Public Printed Name:__________________ My Commission Expires: ________________ Certificate of Delivery I, __________________________________ , hereby certify that I have delivered this day a true and correct copy of the foregoing to __________________________________ by: ( ) Personal Service ( ) Mailing a true and correct copy of same by certified or registered U.S. mail, postage prepaid, return receipt requested to ______________________________________ . So certified this the _____ day of _______________ , 20 _____ . ________________________ Signature Sworn Statement of Account Page 2 of 2