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					                    Construction Sworn Owner’s Statement

STATE OF ILLINOIS            )
                             )ss.
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
                                           CREDITS
                         ARCHITECT




                         SURVEYOR




                         ENGINEER




                         SOIL TESTS




                          GENERAL
                        CONTRACTOR




                          OFF-SITE
                       IMPROVEMENTS




                          OTHERS
*STRIKE ONE*                THE UNDERSIGNED HEREBY APROVES THE ABOVE
                            AMOUNTS FOR PAYMENT.
                             SIGNED________________________________________
                             ADDRESS_______________________________________
    Subscribed and sworn to before me this _______ day of _____________, __________


                              _________________________________
                              Notary Public

				
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posted:8/24/2011
language:English
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