Conditional Partial Waiver And Release Of Lien Form, Form W-9 - Request For Taxpayer Identification Number And Certification Page 3

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SUBCONTRACTOR’S SWORN STATEMENT
State of
Period Ending:
County of
The affiant
(Name) being first duly sworn on oath dispossess and says that he/she is
the
(Position / Title) of
(Company Name) who has a contract with Live
Oak Contracting, LLC., for
(Type of Work) on the following described premises in
County, State of
, located at
(Street Address)
and owned by_______________
___________ 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 on said improvement.
That there is due and to become due them, respectively, the amounts set opposite their names for materials or labor as stated.
That this statement is a full, true and complete statement of all such persons, the amounts paid, and the amounts due or to
become due to each.
ADJUSTED TOTAL
KIND OF WORK
CONTRACT
AMOUNT
AMOUNT OF
BALANCE TO
NAME, ADDRESS,
OR MATERIAL
PREVIOUSLY PAID
THIS PAYMENT
BECOME DUE
(INCL. EXTRAS &
CONTACT PERSON, PHONE #
CREDITS)
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
TOTAL
I agree to furnish Waivers of Lien for all materials under my contract when demanded.
DATED:
Subscribed and sworn to, before me this date of _____________________________, 20 __________________
__________
SIGNED:
Notary Public
ADDRESS:
S TA T E OF
C O UN T Y OF _______ _____________ _________________
My Commission Expires: __________________________________

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