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Sworn Statement of Account State of Florida

County of Before me, the undersigned authority, personally appeared ______________, who after being duly sworn deposes and says that regarding the (describe project) the following is true: 1) Nature of labor or services performed and to be performed: 2) Materials furnished and to be furnished: 3) Amount paid on account to date: $ 0.00 4) Amount due: $ 00.00 ______________________________________ By:__________________________________ The foregoing statement was sworn to or affirmed before me this ___ day of ___________, 20__, by ______________________ on behalf of ________________________________, and who is personally known to me. _____________________________,

Notary Public State of Florida

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15y ago

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