SWORN STATEMENT
STATE OF MICHIGAN )
) ss.
COUNTY OF
)
<<<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. 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
Total
Contract
Price
Amount
Already
Paid
Amount
Currently
Owing
Balance
to
Complete
Amount of
Laborer
Wages Due
But Unpaid
Retention
Amount of Laborer
Fringe Benefits
and Withholdings
Due But Unpaid
SUB TOTALS
91742v2
Name of Subcontractor,
Supplier, or Laborer
Type of
Improvement Furnished
Total
Contract
Price
Amount
Already
Paid
Amount
Currently
Owing
Balance
to
Complete
Amount of
Laborer
Wages Due
But Unpaid
Retention
Amount of Laborer
Fringe Benefits
and Withholdings
Due But Unpaid
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..
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
day of
, 20___.
, Notary Public
County, Michigan
My commission expires:
Acting in _______________ County
SWORN STATEMENT
STATE OF MICHIGAN )
) ss.
COUNTY OF
)
__________________ , being duly sworn, deposes and says: That ______________________ is a/the (contractor)(subcontractor)(supplier) for an improvement to
the following described public works situated in _______
County, Michigan, described as follows:
Contract No. ; Project Name:
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)(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:
Name of Subcontractor,
Supplier, or Laborer
Type of
Improvement Furnished
Total
Contract
Price
Amount
Already
Paid
Amount
Currently
Owing
Balance
to
Complete
Amount of
Laborer
Wages Due
But Unpaid
Retention
Amount of Laborer
Fringe Benefits
and Withholdings
Due But Unpaid
SUB TOTALS
91742
Name of Subcontractor,
Supplier, or Laborer
Type of
Improvement Furnished
Total
Contract
Price
Amount
Already
Paid
Amount
Currently
Owing
Balance
to
Complete
Amount of
Laborer
Wages Due
But Unpaid
Retention
Amount of Laborer
Fringe Benefits
and Withholdings
Due But Unpaid
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 _____ ____
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.
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
day of
, 20___.
, Notary Public
County, Michigan
My commission expires:
Acting in _______________ County
91748v2
FULL CONDITIONAL WAIVER
Our contract with <<<name of company>>> to furnish<<<general description of
work/material furnished. Eg. Concrete work and related items. Eg. Aggregate
materials>>> materials to <<<MDOT>>> Project No. <<<MDOT Contract ID
Number>>> has been fully paid and satisfied with respect to our rights under the
Payment / Lien Bond covering said Project and all of our rights to pursue payment
under the Payment/Lien Bond No. _____________ issued by <<<name of prime
contractor>>> as principal and <<<name of payment bond surety>>> as surety,
together with any rights, demands, or causes of action we may have against _<<<name
of prime contractor>>> or <<<name of payment bond surety>>>, are hereby fully
waived and released and the “Notice of Lien Claim” (if any) dated ,<<<insert “N/A” if
none. Insert date of Notice of Lien Claim if one has been filed>>> and any
amendment(s) thereto, is hereby rescinded.
This waiver is conditioned upon our receipt of payment in the amount of
$<<<amount of payment for which waiver is being given>>>
<TYPE OR PRINT COMPANY NAME>
__________________________
by: <<type or print name>>
its: <<type or print title>>
STATE OF MICHIGAN )
) SS
COUNTY OF )
The signator is known to me and acknowledged the foregoing instrument this
___ day of ________, 20___.
________________________________
____________________, Notary Public
_____________County, Michigan
My commission expires: ___________
Acting In _____________ County
91748
FULL CONDITIONAL WAIVER
Our contract with _________________ to furnish ______________________
materials to _______ Project No. _____________ has been fully paid and satisfied with
respect to our rights under the Payment / Lien Bond covering said Project and all of our
rights to pursue payment under the Payment/Lien Bond No. _____________ issued by
_______________________ as principal and ____________________ as surety,
together with any rights, demands, or causes of action we may have against
_____________________ or __________________ , are hereby fully waived and
released and the “Notice of Lien Claim” (if any) dated _______________, and any
amendment(s) thereto, is hereby rescinded.
This waiver is conditioned upon our receipt of payment in the amount of
$ .
___________________________
__________________________
by: _____________________
its: _____________________
STATE OF MICHIGAN )
) SS
COUNTY OF )
The signator is known to me and acknowledged the foregoing instrument this
___ day of ________, 20___.
________________________________
____________________, Notary Public
_____________County, Michigan
My commission expires: ___________
Acting In _____________ County
91747v2
FULL UNCONDITIONAL WAIVER
Our contract with <<<name of company>>> to furnish general description of
work/material furnished. Eg. Concrete work and related items. Eg. Aggregate
materials>>> materials to <<<MDOT>>> Project No. <<<MDOT Contract ID
Number>>> has been fully paid and satisfied with respect to our rights under the
Payment / Lien Bond covering said Project and all of our rights to pursue payment
under the Payment/Lien Bond No. _____________ issued by <<<name of prime
contractor>>> as principal and <<<name of payment bond surety>>> as surety,
together with any rights, demands, or causes of action we may have against <<<name
of prime contractor>>> or <<<name of payment bond surety>>> , are hereby fully
waived and released and the “Notice of Lien Claim” (if any) dated ,<<<insert “N/A” if
none. Insert date of Notice of Lien Claim if one has been filed>>>, and any
amendment(s) thereto, is hereby rescinded.
<TYPE OR PRINT COMPANY NAME>
__________________________
by: <<type or print name>>
its: <<type or print title>>
STATE OF MICHIGAN )
) SS
COUNTY OF )
The signator is known to me and acknowledged the foregoing instrument this
___ day of ___________, 20___.
________________________________
Notary Public
_____________County, Michigan
My commission expires: ___________
Acting In _____________ County
91747
FULL UNCONDITIONAL WAIVER
Our contract with _________________ to furnish ______________________
materials to ______ Project No._________________ has been fully paid and satisfied
with respect to our rights under the Payment / Lien Bond covering said Project and all of
our rights to pursue payment under the Payment/Lien Bond No. _____________ issued
by _______________________ as principal and ____________________ as surety,
together with any rights, demands, or causes of action we may have against
_____________________ or __________________ , are hereby fully waived and
released and the “Notice of Lien Claim” (if any) dated _______________, and any
amendment(s) thereto, is hereby rescinded.
___________________________
__________________________
by:
its:
STATE OF MICHIGAN )
) SS
COUNTY OF )
The signator is known to me and acknowledged the foregoing instrument this
___ day of ___________, 20___.
________________________________
Notary Public
_____________County, Michigan
My commission expires: ___________
Acting In _____________ County
91744v2
PARTIAL CONDITIONAL WAIVER OF LIEN
Our contract with <<<name of company>>> to furnish <<<general description of
work/material furnished. Eg. Concrete work and related items. Eg. Aggregate
materials>>>to <<<MDOT>>> Project No. <<<MDOT Contract ID Number>>> has
been partially paid and satisfied in the amount of $<<<amount of payment for which
waiver is being given>>>with respect to our rights under the Payment / Lien Bond
covering said Project and our rights to pursue payment under the Payment/Lien Bond
No.
issued by <<<name of prime contractor>>> as principal and
<<<name of payment bond surety>>> as surety, together with any rights, demands, or
causes of action we may have against <<<name of prime contractor>>> or <<<name
of payment bond surety>>> are hereby waived and released to the extent of said partial
payment of $ <<<amount of payment for which waver is being given>>> and the “Notice
of Lien Claim” (if any) dated ,<<<insert “N/A” if none. Insert date of Notice of Lien Claim
if one has been filed>>> and any subsequent amendment(s) thereto, are hereby
rescinded, waived and released for the amount of $ <<<amount of payment for which
waiver is being given>>> and are hereby amended to reflect only the remaining balance
claimed to be due under our contract in the amount of $<<<remaining balance after
deduction of all partial payments to date>>>.
This waiver is conditioned upon our receipt of payment in the amount of
$ <<<amount of payment for which waver is being given>>>
<TYPE OR PRINT COMPANY NAME>
______________________________
by: <<type or print name>>
its: <<type or print title>>
STATE OF MICHIGAN )
) SS
COUNTY OF )
The signator is known to me and acknowledged the foregoing instrument this
___ day of ________, 20___.
________________________________
____________________, Notary Public
_____________County, Michigan
My commission expires: ___________
Acting In _____________ County
91744
PARTIAL CONDITIONAL WAIVER OF LIEN
Our contract with ___________________________ to furnish _____________,
__________________________________ to _________________________ Project
No. _________________________________ has been partially paid and satisfied in
the amount of $___________with respect to our rights under the Payment / Lien Bond
covering said Project and our rights to pursue payment under the Payment/Lien Bond
No. _____________ issued by ____________________________ as principal and
____________________________ as surety, together with any rights, demands, or
causes of action we may have against __________________________ or
_______________________________________ are hereby waived and released to the
extent of said partial payment of $_________ and the “Notice of Lien Claim” (if any)
dated _________________________, and any subsequent amendment(s) thereto, are
hereby rescinded, waived and released for the amount of $____________ and are
hereby amended to reflect only the remaining balance claimed to be due under our
contract in the amount of $___________.
This waiver is conditioned upon our receipt of payment in the amount of
$ .
______________________________
______________________________
by:
its:
STATE OF MICHIGAN )
) SS
COUNTY OF )
The signator is known to me and acknowledged the foregoing instrument this
___ day of ________, 20___.
________________________________
____________________, Notary Public
_____________County, Michigan
My commission expires: ___________
Acting In _____________ County
91743v2
PARTIAL UNCONDITIONAL WAIVER OF LIEN
Our contract with <<<name of company>>> to furnish <<<general description of
work/material furnished. Eg. Concrete work and related items. Eg. Aggregate
materials>>> to <<<MDOT>>> Project No. <<<MDOT Contract ID Number>>> has
been partially paid and satisfied in the amount of $ <<<amount of payment for which
waiver is being given>>>with respect to our rights under the Payment / Lien Bond
covering said Project and our rights to pursue payment under the Payment/Lien Bond
No. _____________ issued by <<<name of prime contractor>>> as principal and
<<<name of payment bond surety>>> as surety, together with any rights, demands, or
causes of action we may have against <<<name of prime contractor>>> or <<<name of
payment bond surety>>> are hereby waived and released to the extent of said partial
payment of $<<<amount of payment for which waver is being given>>> and the “Notice
of Lien Claim” (if any) dated <<<insert “N/A” if none. Insert date of Notice of Lien Claim
if one has been filed>>> and any subsequent amendment(s) thereto, are hereby
rescinded, waived and released for the amount of $ <<<amount of payment for which
waiver is being given>>> and are hereby amended to reflect only the remaining balance
claimed to be due under our contract in the amount of $ <<<remaining balance after
deduction of all partial payments to date>>>.
<TYPE OR PRINT COMPANY NAME>
______________________________
by: <<type or print name>>
its: <<type or print title>>
STATE OF MICHIGAN )
) SS
COUNTY OF )
The signator is known to me and acknowledged the foregoing instrument this
___ day of ________, 20___.
________________________________
____________________, Notary Public
_____________County, Michigan
My commission expires: ___________
Acting In _____________ County
91743
PARTIAL UNCONDITIONAL WAIVER OF LIEN
Our contract with ___________________________ to furnish _____________,
__________________________________ to _________________________ Project
No. _________________________________ has been partially paid and satisfied in
the amount of $___________with respect to our rights under the Payment / Lien Bond
covering said Project and our rights to pursue payment under the Payment/Lien Bond
No. _____________ issued by ____________________________ as principal and
____________________________ as surety, together with any rights, demands, or
causes of action we may have against __________________________ or
_______________________________________ are hereby waived and released to the
extent of said partial payment of $_________ and the “Notice of Lien Claim” (if any)
dated _________________________, and any subsequent amendment(s) thereto, are
hereby rescinded, waived and released for the amount of $____________ and are
hereby amended to reflect only the remaining balance claimed to be due under our
contract in the amount of $___________.
______________________________
______________________________
by:
its:
STATE OF MICHIGAN )
) SS
COUNTY OF )
The signator is known to me and acknowledged the foregoing instrument this
___ day of ________, 20___.
________________________________
____________________, Notary Public
_____________County, Michigan
My commission expires: ___________
Acting In _____________ County
