Fill and Sign the Texas Disbursement Form

Disbursement Statement Page 1 of 2 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: 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 _______________________ ____________________ ______________ __________________ 3. Address Phone Amount to be Paid ____________________ Name _______________________ ____________________ ______________ __________________ Address Phone Amount to be Paid ____________________ Name _______________________ ____________________ ______________ __________________ Address Phone Amount to be Paid ____________________ Name _______________________ ____________________ ______________ __________________ Disbursement Statement Page 2 of 2 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 ____________________ Name _______________________ ____________________ ______________ __________________ Dated this the _____ day of ______________, 20_______. Signature: _____________________________________ Print Name: _____________________________________ Doing Business as: _____________________________________ TX Code § 53.258