Contractors Declaration To Procure Payment

CONTRACTOR'S DECLARATION TO PROCURE PAYMENT FROM: (Name of Person/Firm Making Declaration) (Street Address) (City, State, Zip) PROJECT: (Name of Project) (Address of Project) (City, State, Zip) TO: (Name of Person/Firm to Whom Declaration is Made) (Street Address) (City, State, Zip) DECLARATION (This is not a lien release) The following is a complete list of all persons and firms who have furnished subcontract work, equipment or materials to the above-named firm for the project described above. Full payment for all work, equipment and materials supplied to date has been made except as otherwise stated below. I declare under penalty of perjury that the above statement is true and correct. Signed on (Date) 19 at (City) (Signature of individual who is making declaration) (Name of Subcontractor or Supplier) (Type of Work or Materials Furnished) RELEASE ATTACHED $ FULL CONDITIONAL (Address) (State, City, Zip) (Amount Unpaid - If Full Payment Has Been Made, Write "None" (Name of Subcontractor or Supplier) (Type of Work or Materials Furnished) RELEASE ATTACHED $ FULL CONDITIONAL (Address) (State, City, Zip) (Amount Unpaid - If Full Payment Has Been Made, Write "None" (Name of Subcontractor or Supplier) (Type of Work or Materials RELEASE ATTACHED $ FULL CONDITIONAL (Address) (State, City, Zip) (Amount Unpaid - If Full Payment Has Been Made, Write "None" Continue on page 2 if needed 2001 © American LegalNet, Inc. American LegalNet, Inc. www.FormsWorkFlow.com (Name of Subcontractor or Supplier) (Type of Work or Materials Furnished) RELEASE ATTACHED $ FULL CONDITIONAL (Address) (State, City, Zip Code) (Amount Unpaid - If Full Payment Has Been Made, Write "None" (Name of Subcontractor or Supplier) (Type of Work or Materials Furnished) RELEASE ATTACHED $ (Address) (State, City, Zip Code) FULL CONDITIONAL (Amount Unpaid - If Full Payment Has Been Made, Write "None" (Name of Subcontractor or Supplier) (Type of Work or Materials Furnished) RELEASE ATTACHED $ (Address) (State, City, Zip Code) FULL CONDITIONAL (Amount Unpaid - If Full Payment Has Been Made, Write "None" (Name of Subcontractor or Supplier) (Type of Work or Materials Furnished) RELEASE ATTACHED $ (Address) (State, City, Zip Code) FULL CONDITIONAL (Amount Unpaid - If Full Payment Has Been Made, Write "None" (Name of Subcontractor or Supplier) (Type of Work or Materials Furnished) RELEASE ATTACHED $ (Address) (State, City, Zip Code) FULL CONDITIONAL (Amount Unpaid - If Full Payment Has Been Made, Write "None" INSTRUCTIONS FOR USE OF CONTRACTORS DECLARATION TO PROCURE PAYMENT PURPOSE OF THE "CONTRACTORS DECLARATION TO PROCURE PAYMENT" PROPER USE OF THE FORM: A person holding a construction fund should never make payments for work done to improve the subject property unless he is assured that all persons contributing to that improvement have been or will be paid for their materials or services. This declaration has the effect of minimizing the exposure to unknown lien claims. The declarant must state the names of all persons or firms that did work for him (or supplies him with materials) on the named project. Omission of any names can result in prosecution of the declarant as well as for perjury. In addition, he is subject to disciplinary action by the Contractor's State License Board of his state. The declaration gives the person making the payment a basis for deciding whether or not he wants to require releases, make payment directly to declarant, make payment to the persons named in the declaration and the declarant on a joint check, etc. (a) Whenever a request for construction fund payments are made the person holding the fund should require that the declaration be executed. (b) Upon receipt of the declaration, the person holding the fund can disburse in one of the following manners: (1) In full to the declarant; (2) Require that the declarant obtain full releases (form or conditional releases (form ) prior to payment; (3) Make joint checks to the declarant and all persons listed as ''unpaid'' CAUTION: To obtain the best results from the use of this form the person receiving the form should be sure that there is a full or partial release attached for each name on the list. A convenient space for noting that the release has been received is provided along side of each name space. 2001 © American LegalNet, Inc. American LegalNet, Inc. www.FormsWorkFlow.com