Fill and Sign the Sworn Statement Form 497302809

OWNER'S SWORN STATEMENT CONCERNING DIRECT CONTRACTS- CORPORATION TO: ___________________________________ DATE: ______________________ __________________________________________________ __________________________________________________ (Lienor's name and address) In accordance with Section 713.16(5), Florida Statutes, and in response to your demand for a sworn statement in your letter dated _____ day of ________________ , 20 _____ , the undersigned submits the following Statement: Amount of all direct contracts: $ ________________ Total amount heretofore paid for all labor, services and materials furnished under direct contracts: $ __________________ The dates and amount paid or to be paid under direct contracts (attach continuation sheet if necessary): Date ___________________ Amount $ ___________________ Date ____________________ Amount $ ___________________ Date ____________________ Amount $ ____________________ Date ____________________ Amount $ ____________________ Date ____________________ Amount $ ____________________ Construction (check one) has has not ceased under any direct contract. The amount estimated to complete the improvements according to the terms and specifications of any direct contracts) under which construction has ceased is $ __________________ . The actual cost of completion, if known is $ ___________________ . The undersigned certified that this Statement has been served at the address specified above, on _____ day of __________________ , 20 _____ , in accordance with Section 713.18, Florida Statutes. Owner's Name _________________________ Owner’s Sworn Statement Page 1 of 2 By (signature) __________________________ Type or Print Name _____ _________________ Title _____ _____________________________ Name of Corporation _____ ________________ STATE OF ___________ COUNTY OF _____________ Sworn to (or affirmed) and subscribed before me this _____ day of _________________, 20______ by _________________________ (name of person making statement) who is personally known to me or produced _________________________ as identification, and who did take an oath. ____________________________ NOTARY PUBLIC Printed Name of Notary _________________________ Commission Expires _________________________ Certificate of Service I, _____________________________________, hereby certify that I have delivered this day a true and attested copy of the foregoing to ___________________________________ by: ( ) Actual Delivery to the person to be served. ( ) Mailing a true and correct copy of same by registered or certified U.S. mail, with postage prepaid, or by overnight or second-day delivery with evidence of delivery. ( ) If service cannot be made by the above methods, by posting on the premises. ________________________ Signature Owner’s Sworn Statement Page 2 of 2