Fillable Affidavit Of Contractor Form (Page 2 of 2) in pdf

Affidavit Of Contractor Form Page 2

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Said affiant further says that the following shows the names of every unpaid laborer in the employ

of____________________________, Inc furnishing labor under said contract, giving the amount, if any,

which is due, become due for labor done to date hereof:

NOTE: If the fact is that every laborer has been paid in full, then recite: “Every laborer has been paid in

full.” If not, then give each unpaid laborer’s name and the amount due or to become due.

LABOR

Amount due or to become due for labor

NAME

HOURS

furnished to date hereof

That the amounts due or to become due to said subcontractors, materialmen and laborers, for work done,

or machinery, material or fuel furnished to the date hereof, to________________________, is fully and

correctly set forth opposite their names, respectively, in the aforesaid statements, and further evidenced by

certificates of every person furnishing machinery, material or fuel, hereto attached, and made a part

hereof.

Affiant further says that____________________________, Inc. has not employed or purchased or

procured machinery, material or fuel from, or subcontracted with any person, firm or corporation, other

than those above mentioned, and owes for no labor performed, or machinery, material or fuel furnished

under said contracts, other than above set forth.

AFFIANT

SWORN TO BEFORE ME AND SUBSCRIBED IN MY PRESENCE at Cleveland, Ohio, this

________________day of _________________, 201_.

_________________________

Notary Public

CERTIFICATE OF MATERIALMEN

Cleveland, Ohio

______________________, 201_

The undersigned certify that to the date hereof they have furnished machinery, material or fuel as set out

herein to __________________ for _______________________________________ situated on or

around or in front of the property described in the foregoing affidavit; that the nature of said machinery,

material or fuel furnished, the date when they commenced furnishing the same and the amount now due or

owing to each of them, is correctly stated and set opposite their respective names or they have been paid

in full, if so acknowledge hereon.

Amount Due or to

Machinery, Materials or Fuel

Commenced

Become Due to Date

NAME

and Nature of the Same

Furnishing

Hereof

Affidavit Of Contractor Form Page 2

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