Fill and Sign the Texas Disbursement Form

DISBURSEMENT STATEMENT REQUIRED BEFORE PAYMENT TO ORIGINAL CONTRACTOR RESIDENTIAL CONSTRUCTION - INDIVIDUAL 1. The undersigned is the original contractor on the project identified below. This statement concerns the following residential construction project: Project Name or Address: ____________________________________________________________________ Owner name and Address: ____________________________________________________________________ Short Legal Description ("Real Property"): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 2. This statement is provided to Owner and Lender, if applicable, prior to payment, after demand therefore, and provides the name, address and phone of all subcontractors, materialmen and others who have contracted with the undersigned on the project, and the amount, if any, of the proceeds which will be paid to such subcontractors, materialmen and others entitled thereto: Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ 3. Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Disbursement Statement Page 1 of 2 Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Name _______________________ Address Phone Amount to be Paid ____________________ ______________ __________________ ____________________ Dated this the _____ day of ______________ , 20 _______ . Signature: _____________________________________ Print Name: _____ ________________________________ Doing Business as: _____ ________________________________ TX Code § 53.258 Disbursement Statement Page 2 of 2