The undersigned, being first duly sworn, deposes and says that they are the owner of the following described property in ______________________ County, ________________State, described as follows:
More commonly known as:
Tax I.D. No:
(COMPLETE THIS AFFIDAVIT BY CHECKING THE APPROPRIATE BOX BELOW)
Deponent further says that:
__________ A. There have been no repairs, alterations, remodeling or new construction on the
above described premises in the last ninety (90) days.
__________ B. Deponent has contracted for repairs, alterations, remodeling or new construction
on the above described premises which have been completed within the last ninety
(90) days, Deponent paid for all of said improvements directly to the contractors
and there are no unpaid bills or claims for labor or services or material in con-
nection therewith except as follows: ______________________________________
__________ C. Deponent has contracted with a general contractor for repairs, alterations, remod-
eling or new construction on the above described premises which have been com-
pleted within the last ninety (90) days. The sworn statement of said contractor for
improvements, and appropriate supporting waivers of lien, are submitted herewith.
Deponent has not been served with any notice that a lien will be claimed on the
above described premises for labor performed or material furnished except as
__________ D. Deponent has not other liens on said property other than those described here:
DATED:________________________________ SIGNED BY:
Subscribed and sworn to before me this __________ day of ____________, 20__.
Commission Expires: ______________ __________________________________