Below is the  Sworn Statement For Contractortemplate body. If necessary, please put the personal information, company information, such as text to replace the specific content you need. you can download the .doc template file on the end of the article by click download link. 

APPLICATION FOR PAYMENT AND SWORN STATEMENT
FOR CONTRACTOR AND SUBCONTRACTOR TO OWNER




Development Title              Date     Page No.   of   

Building                Payment Application #      

Owner                Period From        

Architect              Change Orders #      

Contractor              IHDA No.          


1
2
3
4
5
6
7


Contractor
Work/Material Contracted For

Adjusted Total
Contract Including
Change Orders


Work Completed
& Materials Stored
(% & $)

Total Retained
Including This
Application


Previously
Paid

Net Amount
Now Due
Col 3 C Col 4&5

Balance
Become Due
Col 2 C Col 5&6












































































































Amount of Original Contract   $       Work Completed (Col. 3)   $     

Extras to Contract $     $       Total Retained (Col. 4)     $     

Total Contract & Extras $   $       Net Amt Earned (Col. 3 - Col. 4) $     

Credits to Contract $     $       Previously Paid (Col. 5)     $     

Adjusted Total Contract $   $       Net Amt Due (Col. 6)     $     
State of          
County of        

The undersigned       being first duly sworn, on oath deposes and says, that he/she is
The      [TITLE] of         [FIRM NAME]. Contractor for the         [TYPE OF WORK] for the following project          
located at                        

That, for the purpose of this work the foregoing orders have been place and the foregoing parties subcontracted with and these have furnished materials or have provided labor or both, for said project.

That, the amount for such order or subcontract is as stated above and that there is due and to become due them respectively, the amounts set opposite their names for materials or labor or both.

That, this statement is made in compliance with the statutes relating to Mechanics Liens and for the purpose of procuring from the Owner FINAL/PARTIAL payment in accordance with the terms of the contract and is a full, true and complete statement, of all parties furnishing labor and/or material, and of amounts paid, due and to become due them.


Signed this      day of        , 20  .

IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date first above written. 


CONTRACTOR            OWNER



                          
Authorized Signature          Authorized Signature

                          
Print Name and Title          Print Name 



Witness my hand and official seal. 

Signature                            Notary 


(Seal)
Additional Clauses you might want to add:


WARNING TO OWNER: AN OWNER OR LESSEE OF THE DESCRIBED PROPERTY MAY NOT RELY ON THIS SWORN STATEMENT TO AVOID THE CLAIM OF A SUBCONTRACTOR, SUPPLIER, OR LABORER WHO HAS PROVIDED A NOTICE OF FURNISHING PURSUANT TO SECTION 109 OF THE CONSTRUCTION LIEN ACT TO THE DESIGNEE OR TO THE OWNER OR LESSEE IF THE DESIGNEE IS NOT NAMED OR HAS DIED.


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 (contractor) (subcontractor) has (contracted) for performance under the contract with the owner or lessee 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: (Please round to the nearest $)























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