Sworn Statement - County Of Washtenaw
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1
2SWORN STATEMENT
State of Michigan
} §
County of ___Washtenaw______________
________________________________, being duly sworn, states the following:
___________________________________________________________________________________
is the (contractor)(subcontractor) for an improvement to the following real property in _Washtenaw_____
County, Michigan, described as follows: ___________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
The following is a statement of each subcontractor, supplier and laborer, for whom payment of wages or
fringe benefits and withholdings is due but unpaid, with whom the (contractor)(subcontractor) has
(contracted)(subcontracted) for performance under the contract with the owner or lessee, and the
amounts due to the persons as of the date of this statement are correctly and fully set forth opposite their
names:
Name,
Type of
Total
Amount
Amount
Balance to
Amount of
Amount of
Address &
Improvement
Contract
Already Paid
Currently
Complete
Laborer
Fringe
Phone
Furnished
Price
Owing
(optional)
Wages Due
Benefits and
Number of
but Unpaid
Withholdings
Subcontractor,
Due But
Supplier, or
Unpaid
Laborer
Totals
(Some columns may not be applicable to all persons listed)
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