Sworn_Statement by YJeelj8

VIEWS: 0 PAGES: 4

									                                                                                     Sworn Statement
State of                                  Michigan
County of                                                                            ss.


                                                     being duly sworn, deposes and says that                                                                         is the
contractor/subcontractor for an improvement to the following described real property situated in                                                                                   County, Michigan,
described as follows:
That the following is a statement of each subcontractor and supplier and laborer, for which the payment of wages or fringe benefits and withholdings due but unpaid, with whom the
contractor/subcontractor has contracted/subcontracted for performance under the contract with the owner or lessees thereof, and that the amounts due to the persons as of the date hereof
are correctly and fully set forth opposite their names as follows:

                     A                                          B                             C                      D             E                F                 G                    H
      Subcontractor Supplier or Laborer                                                                                       Adjustment to    Amount Already   Amount Currently
No.                                                     Item Description              Total Contract Price    Change Orders                                                        Balance to Complete
      Name, Address and Phone Number                                                                                          Contract Price       Paid             Owing



 1                                        Architectural, Engineer, and Survey                                                              -                                                      -


 2                                        Plans & Specifications                                                                           -                                                      -


 3                                        Permits: Health, Zoning, Building                                                                -                                                      -


 4                                        Sewer/Water Permit Fees                                                                          -                                                      -


 5                                        Temporary Utilities                                                                              -                                                      -


 6                                        Demolition                                                                                       -                                                      -


 7                                        Excavation                                                                                       -                                                      -


 8                                        Footings                                                                                         -                                                      -


 9                                        Foundation                                                                                       -                                                      -


10                                        Retaining Walls, Waterproofing, Drainage                                                         -                                                      -


11                                        Rough Grading, Trenching, Backfill                                                               -                                                      -

                                          Sewer Line Connection or Septic-
12                                        Drainfield                                                                                       -                                                      -

                                          Water Line Connection or Well
13                                        Drilling/Hookup                                                                                  -                                                      -




                                                                                                       Page 1 of 4
      Subcontractor Supplier or Laborer                                                                                Adjustment to    Amount Already   Amount Currently
No.                                                     Item Description       Total Contract Price    Change Orders                                                        Balance to Complete
      Name, Address and Phone Number                                                                                   Contract Price       Paid             Owing



14                                        Foundation or Mortgage Survey                                                             -                                                      -


15                                        Concrete Floors                                                                           -                                                      -


16                                        Steel Beams and Stanchions                                                                -                                                      -


17                                        Rough Lumber                                                                              -                                                      -


18                                        Rough Carpentry Labor                                                                     -                                                      -


19                                        Roofing Supplies/Labor                                                                    -                                                      -


20                                        Windows, Doorwalls, Exterior Doors                                                        -                                                      -


21                                        Garage Doors                                                                              -                                                      -


22                                        Exterior Stairs                                                                           -                                                      -


23                                        Siding                                                                                    -                                                      -


24                                        Brick Supplies_                                                                           -                                                      -


25                                        Brick Labor and Acid Wash                                                                 -                                                      -


26                                        Gutters and Downspouts                                                                    -                                                      -


27                                        Fireplace                                                                                 -                                                      -


28                                        Fire System                                                                               -                                                      -


29                                        Rough Plumbing/Labor and Supplies                                                         -                                                      -


30                                        Rough Heating Supplies                                                                    -                                                      -


31                                        Rough Heating Labor                                                                       -                                                      -


32                                        Rough Electrical Supplies                                                                 -                                                      -



                                                                                                Page 2 of 4
      Subcontractor Supplier or Laborer                                                                                         Adjustment to     Amount Already   Amount Currently
No.                                                    Item Description                 Total Contract Price    Change Orders                                                         Balance to Complete
      Name, Address and Phone Number                                                                                            Contract Price        Paid             Owing


33                                        Rough Electrical Labor                                                                              -                                                      -


34                                        Waterproofing                                                                                       -                                                      -


35                                        Exterior Painting/Staining                                                                          -                                                      -


36                                        Exterior Caulking                                                                                   -                                                      -


37                                        Insulation Materials/Labor                                                                          -                                                      -


38                                        Drywall Materials                                                                                   -                                                      -


39                                        Drywall Hanging and Finishing Labor                                                                 -                                                      -


40                                        Finish Trim Materials                                                                               -                                                      -

                                          Bathroom and Kitchen Cabinets & Counter
41                                        Tops                                                                                                -                                                      -


42                                        Finish Trim Labor                                                                                   -                                                      -

                                          Interior Painting, Staining, Wall Covering,
43                                        Caulking                                                                                            -                                                      -


44                                        Tile/Granite/Marble                                                                                 -                                                      -

                                          Floor Coverings: Carpeting, linoleum, and
45                                        hardwood flooring                                                                                   -                                                      -


46                                        Finish Plumbing Labor and Supplies                                                                  -                                                      -

                                          Finish Electrical: Lights, hardware, &
47                                        Labor                                                                                               -                                                      -


48                                        Finish Heating/Air Conditioning                                                                     -                                                      -


49                                        Appliances                                                                                          -                                                      -


50                                        Final Grading                                                                                       -                                                      -


51                                        Driveways, Walkways                                                                                 -                                                      -
    Subcontractor Supplier or Laborer                                                                                           Adjustment to     Amount Already   Amount Currently
No.                                                    Item Description                 Total Contract Price    Change Orders                                                         Balance to Complete
    Name, Address and Phone Number                                                                                              Contract Price        Paid             Owing


                                                                                                         Page 3 of 4
52                                             Fences                                                                                                  -                                                         -


53                                             Landscaping/Sprinkler System                                                                            -                                                         -


54                                             Security System                                                                                         -                                                         -


55                                             Final Cleanup                                                                                           -                                                         -


56                                             Certificate of Occupancy                                                                                -                                                         -


57                                                                                                                                                     -                                                         -


58                                                                                                                                                     -                                                         -


59                                                                                                                                                     -                                                         -
                                               TOTALS                                         $                 -       $         -   $                -       $               -   $              -   $          -



That the contractor has not procured material from, or subcontracted with, any person                                                 WARNING TO DEPONENT: A PERSON, WHO WITH INTENT TO DEFRAUD, GIVES
other than those set forth and owes no money for the improvement other than the sums                                                  A FALSE SWORN STATEMENT IS SUBJECT TO CRIMINAL PENALTIES AS
set forth above.                                                                                                                      PROVIDED IN SECTION 110 OF THE CONSTRUCTION LIEN ACT. ACT NO. 497 OF
                                                                                                                                      THE PUBLIC ACTS OF 1980, AS AMENDED, BEING SECTION 570.1110 OF THE
Deponent further says that he or she makes the foregoing statement as the (contractor)(subcontractor) or as                           MICHIGAN COMPILED LAWS.
                                                of the (contractor) (subcontractor) for the purpose of
representing to the owner or lessee of the above described premises and his or her agents that the above
described property is free from claims of construction liens, or the possibility of construction liens, except as                     ____________________________________________________________________
specifically set forth above and except for claims of construction liens by laborers which may be provided                            Print Name:                                             -Deponent
pursuant to section 109 of the construction lien act, Act No. 497 of the Public Acts of 1980, as ameded, being
Section570.1109 of the Michigan Compiled Laws.

                                                                                                                                      Subscribed and sworn to before me this                          day of
WARNING TO OWNER: AN OWNER OR LESSEE OF THE ABOVE DESCRIBED PROPERTY                                                                                                               , 2008
MAY NOT RELY ON THIS SWORN STATEMENT TO AVOID THE CLAIM OF A SUBCONTRACTOR,
SUPPLIER, OR LABORER WHO HAS PROVIDED A NOTICE OR FURNISHING OR A                                                                     ___________________________________________________________________
LABORER WHO MAY PROVIDE A NOTICE OF FURNISHING UNDER TO SECTION
109 OF THE CONSTRUCTION LIEN ACT 1980 P.A. 497, MCL 570.1109 TO THE DESIGNEE                                                          Notary Public,                                    County,       Michigan
OR TO THE OWNER OR LESSEE IF THE DESIGNEE IS NOT NAMED OR HAS DIED.
                                                                                                                                      Acting in                                         County,       Michigan
ON RECEIPT OF THIS SWORN STATEMENT, THE OWNER OR LESSEE, OR THE OWNER'S OR LESSEE'S
DESIGNEE, MUST GIVE NOTICE OF ITS RECEIPT, EITHER IN WRITING, BY TELEPHONE, OR PERSONALLY,                                            My commission expires:
TO EACH SUBCONTRACTOR, SUPPLIER, AND LABORER WHO HAS PROVIDED A NOTICE OF FURNISHING
UNDER SECTION 109 OR, IF A NOTICE OF FURNISHING IS EXCUSED UNDER SECTION 108 OR 108A, TO EACH
SUBCONTRACTOR, SUPPLIER, AND LABORER NAMED IN THE SWORN STATEMENT. IF A SUBCONTRACTOR
SUPPLIER, OR LABORER WHO HAS PROVIDED A NOTICE OF FURNISHING OR WHO IS NAMED IN THE
SWORN STATEMENT MAKES A REQUEST, THE OWNER, LESSEE, OR DESIGNEE SHALL PROVIDE THE
REQUESTER A COPY OF THE SWORN STATEMENT WITHIN 10 BUSINESS DAYS AFTER RECEIVING THE REQUEST.




                                                                                                                    Page 4 of 4

								
To top