SWORN STATEMENT by 62970Kr

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									                                                                              SWORN STATEMENT
Commitment No._________________________________________________________________                            with the owner or lessee thereof, and that the amounts due to the persons as of the
                                                                                                           date
Lender: ________________________________________________________________________                           hereof are correctly and fully set forth opposite their names.
Bank Office: ____________________________________________________________________
Owner: ________________________________________________________________________                            That (he) (she) has not employed or procured material from, contracted or
                                                                                                           subcontracted
State of Michigan, County of: ______________________________________________________                       with, any persons, firm, or corporation other than those below-mentioned, and owes
                                                                                                           no
________________________________________________________________, being duly sworn                         monies for the construction of said buildings or improvements other than the sums set
                                                                                                           forth
deposes and says that ____________________________________________________________                         hereinafter.
is the (owner, contractor, or subcontractor) of/for an improvement to the following described
real property situated in the ___________________________ of _________________________                     The (he) (she) makes the foregoing statement as the (owner) (contractor)
                                                                                                           (subcontractor)
County of _____________________ Michigan, described as follows _______________________                     or as the (owner) (contractor) (subcontractor) for the purpose of representing to the
______________________________ commonly known as: ___________________________                              owner or lessee of the aforementioned premises and his or her agents and the
                                                                                                                                           mortgagee
That the following is a complete statement of each contractor, subcontractor, supplier and                 and ____________________________ that the aforementioned property free from
                                                                                                           claims
laborer, for which laborer the payment of wages or fringe benefits and withholdings is due                 of construction liens, or the possibility of construction liens except as specifically set
                                                                                                           forth
But unpaid, and for which laborer the payment of fringe benefits and withholdings is earned                below.
But unpaid, with whom the (contractor) (subcontractor) for performance under the contract


                                                                                                           TOTAL          ADJUSTED            AMOUNT
                     NAME, ADDRESS, AND TELEPHONE NUMBER OF                        TYPE OF IMPROVEMENT                                                          CURRENT              BALANCE TO
                                                                                                         CONTRACT         CONTRACT            ALREADY
                       SUBCONTRACTOR, SUPPLIER OR LABORER                               FURNISHED                                                               REQUEST               COMPLETE
                                                                                                           PRICE           AMOUNT               PAID

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 WARNING TO OWNER OR LESSEE: AN OWNER OR LESSEE OF THE PROPERTY SHALL NOT RELY ON THIS SWORN STATEMENT TO
 AVOID THE CLAIM OF A SUBCONTRACTOR, SUPPLIER, OR LABORER WHO HAS PROVIDED A NOTICE OF FURNISHING OR A
 LABORER WHO MAY PROVIDE A NOTICE OF FURNISHING UNDER SECTION 109 OF THE CONSTRUCTION LIEN ACT, 1980 PA 497,
 MCL 570.1109, TO THE DESIGNEE OR TO THE OWNER OR LESSEE IF THE DESIGNEE IS NOT NAMED OR HAS DIED.
SUBTOTALS CONTINUED ON THE NEXT PAGE
             NAME, ADDRESS, AND TELEPHONE                                                                                     ADJUSTED
                                                                 TYPE OF IMPROVEMENT                         TOTAL CONTRACT                        AMOUNT               CURRENT                BALANCE TO
              NUMBER OF SUBCONTRACTOR,                                                                                        CONTRACT
                                                                      FURNISHED                                   PRICE                          ALREADY PAID           REQUEST                 COMPLETE
                 SUPPLIER OR LABORER                                                                                           AMOUNT

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                                                  TOTALS


IF THIS SWORN STATEMENT IS IN REGARDS TO A RESIDENTIAL STRUCTURE, ON RECEIPT OF                                                                             WAIVER OF LIEN
THE 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, TO
                                                                                                                               For a valuable consideration, paid to the undersigned, the receipt whereof is
EACH SUBCONTRACTOR, SUPPLIER, AND LABORER WHO HAS PROVIDED A NOTICE OF                                                         hereby confessed and acknowledged, the undersigned hereby waive, release,
FURNISHING UNDER SECTION 109 OR, IF A NOTICE OF FURNISHING IS EXCUSED UNDER                                                    and relinquish any and all claims or right of lien which the undersigned now
SECTION 108 OR 108A, TO EACH SUBCONTRACTOR, SUPPLIER, AND LABORER NAMED IN THE                                                 have or may have hereafter upon the premises described in the above sworn
SWORN STATEMENT. IF A SUBCONTRACTOR, SUPPLIER, OR LABORER WHO IS ENTITLED TO                                                   statement, for labor and material, general supervisions construction, or
NOTICE OF RECEIPT OF THE SWORN STATEMENT MAKES A REQUEST, THE OWNER, LESSEE, OR                                                otherwise.
DESIGNEE SHALL PROVIDE THE REQUESTER A COPY OF THE SWORN STATEMENT WITHIN 10
BUSINESS DAYS AFTER RECEIVING THE REQUEST.
WARNING TO DEPONENT: A person with intent to defraud, gives a false sworn statement is subject to                                _____________________________________________________________________
criminal penalties provided in Section 110 of the Construction Lien Act, Act No. 497 of the Public Acts of 1980,                                                 (L.S.)
as amended, being Section 570, 1110 of the Michigan Complied Laws.
                                                                                                                               Date___________________________________________________________
_________________________________             _____________________________________
                Deponent                                       Date                                                              By___________________________________________________________
Subscribed and sworn to before me this ____________________________________
by __________________________________________________________________
Notary Public ____________________________________________ County, Michigan
My commission expires __________________________________________________

								
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