Fill and Sign the Verified Statement Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: Company: Address: City: State: Zip: Phone: Fax: Parcel Identification Number: Legal Description: VERIFIED STATEMENT OF ACCOUNT--INDIVIDUAL (Iowa Code Ann. §572.8) COMES NOW, ____________________________, as a party who has furnished labor or materials for the improvement of property described as ____________________ _______________________________________________________________________, and would state as follows: 1. The undersigned began furnishing labor and/or materials to the above-described property on the ____ day of ___________, 20___, and completed furnishing the same on the ____ day of ______________, 20___. 2. The name and last known mailing address of the owner, agent, or trustee of the property is ______________________________________________________________. Verified Statement of Account Page 1 of 3 3. An accounting of the material furnished or labor performed: Material Furnished/Labor Performed Date(s) Amount Due ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ 4. The total amount due the undersigned, allowing for all credits is $ ____________. 5. If the undersigned is not a contractor or subcontractor, the undersigned hereby certifies that a notice containing the name, mailing address, and telephone number of the undersigned, along with the name of the subcontractor to whom labor and/or materials was furnished, was provided to the principal contractor within thirty (30) days of the first furnishing of labor and/or materials, and is attached hereto. This the ______ day of _______________________, 20____. ______________________________ Signature I, _______________________________, do hereby swear or affirm that the matters alleged and things contained in the above Verified Statement of Account are true and correct to the best of my knowledge, information, and belief. ________________________ Affiant STATE OF _____________________ COUNTY OF ____________________ In _______________, on the _____________ day of ____________, 20___, before me, a Notary Public in and for the above state and county, personally appeared _____________________________________________, known to me or proved to be the person named in and who executed the foregoing Verified Statement of Account, and being first duly sworn, such person acknowledged that he or she executed said instrument for the purposes therein contained as his or her free and voluntary act and deed. Type of ID Produced: _________________________ Verified Statement of Account Page 2 of 3 Affiant __ is __ is not personally known to me _______________________________ NOTARY PUBLIC My Commission Expires: ____________________ (SEAL) IA § 572.8 Verified Statement of Account Page 3 of 3