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This is a sworn statement provided by a contractor affirming that they understand the duties and specifications of the job they were hired to perform for the customer. This statement includes a “Schedule A” that provides the details of the services, equipment, labor, and materials related to the project. An estimate of the costs of the labor and the materials are also included “Schedule A.” This statement can be used by contactors to affirm they understand the project’s objectives and they are providing accurate estimates.
This is a sworn statement provided by a contractor affirming that they understand the duties and specifications of the job they were hired to perform for the customer. This statement includes a “Schedule A” that provides the details of the services, equipment, labor, and materials related to the project. An estimate of the costs of the labor and the materials are also included “Schedule A.” This statement can be used by contactors to affirm they understand the project’s objectives and they are providing accurate estimates. SWORN STATEMENT FOR A CONTRACTOR STATE OF ________________, [Instruction: insert name of state] COUNTY OF _________________________ [Instruction: insert name of county] The undersigned, being duly sworn, on oath deposes and says that (s)he is the _________________ [Instruction: insert title of contractor] (Title) of the _______________________, [Instruction: insert name of contractor’s firm] (Firm), the contractor having been hired by _______________________ [Instruction: insert the name of the individual or company that has hired the Contractor] (the “Owner”) to furnish labor and materials for the __________________ [Instruction: insert the title or a brief description of the project] work on the buildings located at: __________________________________________ [Instruction: insert the address where the project will take place] (hereinafter the “Project”). The total amount of the contract is _________________ ($_______) [Instruction: insert dollar amount], of which I have received payment of ___________________ ($_______) [Instruction: insert dollar amount] as of the date of my signature below. The persons, firms, and corporations that I intend to engage to furnish services, equipment, labor and/or materials related to the Project are identified on Schedule A attached hereto. The dollar amount set opposite each such person, firm, or corporation on Schedule A is the estimated amount that will be due or to each such person, firm, or corporation on account of labor, services, equipment, and/or materials furnished with respect to the Project. As of this date, all work to be performed with respect to the Project by the undersigned or any suppliers or subcontractors of the undersigned or any of the persons, firms, or corporations named in the Schedule A of this Sworn Statement, has been fully accepted by the Owner. The undersigned further states that all material (except as disclosed on said Schedule A) has been or will be furnished from his/her own stock and has been paid for in full; that there are no other contracts or subcontracts for said work outstanding, and that there is nothing due or to become due to any person for services, equipment, material, labor, or any other work done or to be done in connections with said work other than that stated on Schedule A. There are no chattel mortgages, personal property leases, conditional sale contracts or any other agreements given are now outstanding as to any fixtures, equipment, appliances or materials placed upon or installed in or upon the aforementioned premises or improvements thereon. All waivers are true, correct, and genuine and are delivered unconditionally. Furthermore, there is no claim, either legal or equitable; to defeat the validity of said waivers. I, ________________ [Instruction: insert Contractor’s name] affirm and declare under penalty of perjury under the laws of the State of ________ [Instruction: insert name of state], that the information I have provided is true and complete to the best of my knowledge. Furthermore, I have made these statements without threat, coercion or unlawful influence, or inducement. Signed this _________ day of ___________, __________ [Instruction: insert date] ________________________________________ Notary Subscribed and sworn to before me this ________ day of _________________, 20 ___. Notary Public: __________________________, County of __________, ____________ [Insert County and State] My Commission Expires: ____________________ © Copyright 2011 Docstoc Inc. 3 SCHEDULE A Name and Kind of Amount of Retention Net of Net Amount Balance to Address Work Contract (incl. Previous This Become Due Current) Payments Payment (incl. Retentions) Amount of Original Contract $__________________ Work Completed to Date $__________________ Extras to Contract $__________________ Less ______% Retained $__________________ Total Contract & Extras $___________________ Net Amount Earned $__________________ Credits to Contract $___________________ Adjusted Total Contract $___________________ Net Previously Paid $__________________ Net Amount of the Payment $__________________ Balance to Become Due $___________________ (incl. Retention) © Copyright 2011 Docstoc Inc. 4
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