Michigan Sworn Statement PDF Form

SWORN STATEMENT STATE OF MICHIGAN COUNTY OF ss. name of person signing sworn statement being duly sworn deposes and says That name of company is a/the select one contractor subcontractor supplier for an improvement to the following described public works situated in County Michigan described as follows Contract No. MDOT Contract ID Number Project Name eg. WARNING TO DEPONENT A PERSON WHO WITH INTENT TO DEFRAUD GIVES A FALSE SWORN STATEMENT FOR THE PURPOSE OF OBTAINING PAYMENT IS SUBJECT TO CRIMINAL and CIIVIL PENALTIES AS PROVIDED BY LAW. Deponent Subscribed and sworn to before me this 20. Notary Public County Michigan My commission expires Acting in County 91742v2 day of being duly sworn deposes and says That the following described public works situated in is a/the contractor subcontractor supplier for an improvement to Project Name whom the contractor subcontractor supplier has contracted subcontracted supplied material supplied labor for the improvement on the above referenced public works project and that the amounts due to the persons as of the date hereof are correctly and fully set forth opposite their names as follows of the contractor subcontractor supplier for the purposes of representing to the party from whom payment is requested and to the prime contractor who has furnished a payment bond covering the public works project described on the reverse side and his or her agents that the public works described on the reverse side is free from claims of payment bond liens or the possibility of payment bond liens except as specially set forth on the reverse side hereof. FULL CONDITIONAL WAIVER Our contract with name of company to furnish general description of work/material furnished. Eg. I-96 from U. S 23 to Kent Road That the following is a statement of each subcontractor and supplier and laborer for which laborer the payment of wages or fringe benefits and withholdings is due but unpaid with whom the same selection as above contractor subcontractor supplier has select one contracted subcontracted supplied material supplied labor for performance under the contract with the owner lessee or general contractor thereof and that the amounts due to the persons as of the date hereof are correctly and fully set forth opposite their names as follows Name of Subcontractor Supplier or Laborer Type of Improvement Furnished SUB TOTALS Total Contract Price Amount Already Paid Currently Owing Balance to Complete Laborer Wages Due But Unpaid Retention Amount of Laborer Fringe Benefits and Withholdings TOTALS That the contractor subcontractor has not procured material from or subcontracted with any person other than those set forth on the reverse side and owes no money for the improvement other than the sums set forth on the reverse side. Deponent further says that he or she makes the foregoing statement as the contractor subcontractor supplier or as authorized agent if signator is not officer or employee of company of the contractor subcontractor supplier for the purposes of representing to the owner lessee or general contractor of the public works described on the reverse side and his or her agents that the public works described on the reverse side is free from claims of construction or bond liens or the possibility of construction or bond liens except as specially set forth on the reverse side hereof*.