Fill and Sign the Sworn Statement Individual Michigan Form

SWORN STATEMENT--INDIVIDUAL State of Michigan ) ) County of _______________ ) ________________________________ , being duly sworn, states the following: __________________________________ is the (contractor) (subcontractor) for an improvement to the following real property in ___________________________________ County, Michigan, described as follows: [Insert Legal Description] ______________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . The following is a statement of each subcontractor, supplier and laborer, for whom payment of wages or fringe benefits and withholdings is due but unpaid, with whom the (contractor) (subcontractor) has (contracted) (subcontracted) for performance under the contract with the owner or lessee, and the amounts due to the persons as of the date of this statement are correctly and fully set forth opposite their names: Name, Address and Phone Number of Subcontractor, Supplier, or Laborer Type of Improvement Furnished Total Contract Price Amount Already Paid Amount Currently Owing Balance to Complete (optional) Amount of Laborer Wages Due but Unpaid Amount of Laborer Fringe Benefits and Withholdings Due but Unpaid _ _______________________________________________________________________ _ _______________________________________________________________________ _ _______________________________________________________________________ _ _______________________________________________________________________ _ _______________________________________________________________________ _ _______________________________________________________________________ _ _______________________________________________________________________ _ _______________________________________________________________________ _ _______________________________________________________________________ _ _______________________________________________________________________ _ _______________________________________________________________________ _ _______________________________________________________________________ Totals: _________________________________________________________________ (Some columns may not be applicable to all persons listed) The contractor has not procured material from, or subcontracted with, any person other than those set forth and owes no money for the improvement other than the sums set forth. * Sworn Statement Page 1 of 3 I make this statement as the (contractor) (subcontractor) or as _________________________________ of the (contractor) (subcontractor) to represent to the owner or lessee of the property and his or her agents that the property is free from claims of construction liens, or the possibility of construction liens, except as specifically set forth in this statement and except for claims of construction liens by laborers that may be provided under Section 109 of the Construction Lien Act, 1980 PA 497, MCL 570.1109 WARNING TO OWNER OR LESSEE: AN OWNER OR LESSEE OF THE PROPERTY MAY NOT RELY ON THIS SWORN STATEMENT TO AVOID THE CLAIM OF A SUBCONTRACTOR, SUPPLIER, OR LABORER WHO HAS PROVIDED A NOTICE OF FURNISHING OR A LABORER WHO MAY PROVIDE A NOTICE OF FURNISHING UNDER SECTION 109 OF THE CONSTRUCTION LIEN ACT, 1980 PA 497, MCL 570.1109 TO THE DESIGNEE OR TO THE OWNER OR LESSEE IF THE DESIGNEE IS NOT NAMED OR HAS DIED. IF THIS SWORN STATEMENT IS IN REGARD TO A RESIDENTIAL STRUCTURE, ON RECEIPT OF THIS SWORN STATEMENT, THE OWNER OR LESSEE, OR THE OWNER’S OR LESSEE’S DESIGNEE MUST GIVE NOTICE OF ITS RECEIPT, EITHER IN WRITING, OR BY TELEPHONE, OR PERSONALLY, TO EACH SUBCONTRACTOR, SUPPLIER, AND LABORER WHO HAS PROVIDED A NOTICE OF FURNISHING UNDER SECTION 109 OR, IF A NOTICE OF FURNISHING IS EXCUSED UNDER SECTION 108 OR 108A, TO EACH SUBCONTRACTOR, SUPPLIER, AND LABORER NAMED IN THE SWORN STATEMENT. IF A SUBCONTRACTOR, SUPPLIER WHO HAS PROVIDED A NOTICE OF FURNISHING OR WHO IS NAMED IN THE SWORN STATEMENT MAKES A REQUEST, THE OWNER, LESSEE, OR DESIGNEE SHALL PROVIDE THE REQUESTER A COPY OF THE SWORN STATEMENT WITHIN 10 BUSINESS DAYS AFTER RECEIVING THE REQUEST. ________________________ Deponent _____ ___________________ Type or Print Name WARNING TO DEPONDENT: A PERSON WHO GIVES A FALSE SWORN STATEMENT WITH INTENT TO DEFRAUD IS SUBJECT TO CRIMINAL PENALTIES AS PROVIDED IN SECTION 110 OF THE CONSTRUCTION LIEN ACT, 1980 PA 497, MCL 570.1110. Sworn Statement Page 2 of 3 Subscribed and sworn to by _______________________ before me on the ___ day of 20____ . Signature: _________________________________ Printed Name: _____________________________ Notary public, State of Michigan, County of ____ My commission expires______________________ *Materials furnished by a contractor or a subcontractor out of his or her own inventory, and which has not been purchased specifically for the purpose of performing the contract, need not be listed. Sworn Statement Page 3 of 3