Construction Sworn Owner’s Statement
STATE OF ILLINOIS )
COUNTY OF ) Escrow No. _____________
The Affiant, __________________________________________ being first duly sworn,
on oath deposes and says that he is the *owner/beneficiary of Trust No. ____________
held be _______________________________ which is the *owner/beneficiary of Trust
No.__________ held by _________________________________________which is the
owner* of the following described premises in ___________________________
County, Illinois, to wit: ____________________________________________________
1. That he is thoroughly familiar with all the facts and circumstances concerning the
premises described above.
2. That with respect to improvements on the premises the only work done or material
furnished to date are listed above.
3. That the only contracts let for the furnishing of future work or materials relative to the
contemplated improvements are as listed below.
4. That this statement is a true and complete statement of all such contracts, previous
payments and balances due, if any.
NAME & ADDRESS KIND OF WORK ADJUSTED PREVIOUSLY AMOUNT OF BALANCE TO
TOTAL PAID THIS BECOME DUE
INC.EXTRAS & PAYMENT
*STRIKE ONE* THE UNDERSIGNED HEREBY APROVES THE ABOVE
AMOUNTS FOR PAYMENT.
Subscribed and sworn to before me this _______ day of _____________, __________