Enter the date for statement #5 before making its PDF.

Sworn statement #5

Job # John D. Mcclain house · every box starts as statement #4 left it (the job # never changes; Lien Wav starts at No, each payout needs a new waiver; the date and notes are for this statement only). Change anything here for this payout; orange boxes are changes made on this statement. Everything entered here carries to statement 6. Type the amount paid this statement under AMOUNT THIS STMT. Paid to date and Unpaid balance update as you type. When this statement goes to the bank, press Save and close; statement #6 is then used for the next payout.

Statement #1 is still open. Changes made there also carry to this statement.

GENERAL CONTRACTOR'S SWORN STATEMENT (#5) PAGE 1

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JOB #, NAME OR FILE NAME:	John D. Mcclain house	DATE:
STATE OF :
COUNTY OF :

DESCRIPTION OF WORK

THE AFFIANT, BEING FIRST DUTY SWORN, ON OATH DEPOSES AND SAYS THAT (HE/SHE) IS OF , GENERAL CONTRACTOR WITH OWNER, FOR THE FURNISHING OF ALL MATERIALS, LABOR AND SERVICES FOR THE ERECTION OF ON THE PREMISES COMMONLY KNOWN AS AND LEGALLY DESCRIBED AS IN COUNTY AND SPECIFICATIONS HERETOFORE APPROVED BY OWNER, THAT AFFIANT IS DULY AUTHORIZED TO MAKE THIS STATEMENT ON BEHALF OF THE GENERAL CONTRACTOR; THAT THE TABULATION ON THE FOLLOWING PAGES HEREOF CONTAINS AN ACCURATE AND COMPLETE STATEMENT OF (A) NAME AND ADDRESS OF ALL PARTIES FURNISHING MATERIALS, LABOR, OR SERVICES IN COMPLETION OF THE ABOVE (DESCRIPTION OF WORK) AND CONTRACT SIGN BY OWNER GENERAL CONTRACTOR, <B> WORK AND MATERIALS TO BE FURNISHED BY SAID PARTIES, <C> THE FULL PRICE FOR WORK AND MATERIALS FURNISHED BY SAID PARTIES; TO INCLUDE ALL EXTRAS (CONTRACT PRICE) COLUMN AND ANY (UNPAID BALANCE) COLUMN FOR THE AMOUNT DUE SAID PARTIES AND <D> (FULL PRICE) COLUMN FOR GOOD FAITH ESTIMATES OF WORK TO BE DONE (DESCRIPTION OF WORK) COLUMNS AND SIGNED CONTRACT AND NOT YET CONTRACTED. THE TOTAL OF THE (UNPAID BALANCE) COLUMN AND THE GENERAL CONTRACTORS OVERHEAD AND PROFIT IS SUFFICIENT TO COMPLETE THE THE ABOVE (DESCRIPTION OF WORK) COLUMNS AND SIGNED CONTRACT AND THAT THIS SWORN STATEMENT IS MADE PURSUANT TO THE STATE STATUTE RELATING TO MECHANICS' LIENS TO INDUCE THE OWNER OR HIS AGENT TO MAKE PAYMENT REQUESTED IN SAID TABULATIONS, IN THE AMOUNT Sum OF $.

TOTAL BID PRICE .............................. 3,200

NOTES:

TRADES OR MATERIALS	CONTRACT PRICE	PAID TO DATE	UNPAID BALANCE	Lien Wav
		1,900	1,300	No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
TOTALS THIS PAGE ............................................	3,200	1,900	1,300

GENERAL CONTRACTOR'S SWORN STATEMENT (#5) PAGE 2

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TRADES OR MATERIALS	NAME AND ADDRESS OF SUBCONTRACTOR	CONTRACT PRICE	PAID TO DATE	AMOUNT THIS STMT.	UNPAID BALANCE	Lien Wav
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
						No
TOTALS THIS PAGE ............................................

GENERAL CONTRACTOR'S SWORN STATEMENT (#5) PAGE 3

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TRADES OR MATERIALS	CONTRACT PRICE	PAID TO DATE	UNPAID BALANCE	Lien Wav
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
				No
OWNER PAYMENTS TO SUBS				No
CONTRACTOR'S P/L				No
TOTALS THIS PAGE ............................................
TOTALS PAGES 1 AND 2 ............................................	3,200	1,900	1,300

GENERAL CONTRACTOR'S SWORN STATEMENT (#5) PAGE 4

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PAID SUBCONTRACTORS (LAST STATEMENTS)	........................	1,900
PAID SUBS BY CONTRACTOR (LAST STATEMENTS)
CONTRACTOR CASH TO SUBS (receipt by sub required)	........................
PAYMENT REQUESTED	........................
BALANCE TO COMPLETE THE WORK	........................	1,300
TOTAL MUST EQUAL "BID PRICE" BELOW	........................	3,200
"BID PRICE"	........................	3,200

Contractors signature ______________________________________________________

NOTARY PUBLIC

Subscribed and sworn to before me this ___________ day of ________________________, __________

Notary signature ______________________________________________________

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