Sworn Statement of Account
STATE
OF
COUNTY OF ______________.
BEFORE ME, the undersigned notary
public, personally appeared ________________________, who was duly sworn and
says that he/she is the ______________________________of ___________ and
that in pursuance of a contract with __________________________, Lienor
furnished labor, services, or materials consisting of _________________________________________________________________________
on the following described real property _____________________________ owned by ________________________________, and
makes this affidavit pursuant to Florida Statutes Section 713.16.
Materials
furnished:
Materials
to be furnished:
Labor
or services performed:
Labor
or services to be performed:
Amount
paid on account to date:
Amount
due:
Amount
to become due:
Company
Name: _________________________________________
By: ___________________________________________________
Address
________________________________________________
_______________________________________________________
SWORN TO AND SUBSCRIBED before me by
_______________________________________ who is personally known to me or produced
__________________________________ as identification, and who did _____ take an oath, this ________ day of
_________________________, ______.
Signature
of Notary______________________________________
Printed
Name of Notary __________________________________
Commission
No/Expiration _______________________________
SEAL: