Final Sales Tax Affidavit (Page 4 of 10) in pdf

Final Sworn Statement for Contractor and Subcontractor to Owner

State of ______________________________

Draw Period Ending: ______________________________

County of ____________________________

The affiant (1)______________________________ being first duly sworn on oath dispossess and says that he/she is the (2)______________________________ of

(3)______________________________ who has an agreement with SUMMIT CONTRACTING GROUP, INC., for (4)______________________________ on the following described

premises in said county in which located (5)______________________________ and owned by (6)______________________________. That for the purpose of said agreement, the

following persons have been contracted with and have furnished, or are furnishing and preparing material for, and have done or are doing labor and/or materials on said improvement.

That there are not persons with contracts for labor and/or materials for said improvement. That there is due and to become said persons, respectively, the amounts set opposite their names

for materials or labor as stated. That all lien waivers provided to Owner are true, correct and genuine and delivered unconditionally and that there is no claim either legal or equitable to

defeat the validity of said waivers. That this statement is made to said Owner for the purpose of procuring from said Owner. (7)______________________________ payment on said

contract, and is full, true and complete statement of all such persons, and of the payments paid, due and to become due them.

(1) Executor’s Name (2) Executor’s Title (3) Firm Name (4) General Work Description (5) Site Location (6) Owner (7) Payment Type

Name of Supplier

Total

Amount

Contact Person

Contracted

Contract

Due To Supplier

Phone Number

For

Amount With