Copyright ©2005 Greater Illinois Title Company. All Rights Reserved. http://gitc.com/forms/
Compliments of Greater Illinois Title Company; for Internal and External Use.
Unive
rsal Doc Ref: GP_IEF0027-20050804-R1-0
GREATER ILLINOIS TITLE COMPANY
SWORN STATEMENT OF CONTRACTOR AND SUBCONTRACTOR
TO OWNER AND TO GREATER ILLINOIS TITLE COMPANY
STATE OF ILLI
NOIS
Page___________ of ___________ Pages
COUNTY OF _________________________
} ss.
The affiant, _____________________________________________________________________________ being first duly sworn, on oath deposes
and says that he is _______________________________________________________________
________________________________________
of _______________________________________________________________
__________________________________that ___________ has
contract with _______________________________________________________________
___________________ , owner ______________ for
______________________________________________________________________________________________________________________
o
n the followin
g described premises in said County, to wit:________________________________________________________________________
That, for t
he purposes of said contract, the following persons have been contracted with, and have furnished, or are furnishing and preparing
materials f
or, and have done or are doing labor on said improvement. That there is due and to become due them, respectively, the amounts set
opposite their names for materials or labor as s
tated. That this statement is a full, true and complete statement of all such persons, the amounts paid
and the amounts due or
to become due to each.
1 2 3 4 5 6 7
Name and Address Kind of Work
Amount of
Contract
Retention
(inc. Current)
N
et of Previous
Payments
Net Amount
T
his Payme
nt
Balance To
B
ecome Due
(Inc
. Retentions)
TOTAL
WORK COMPLETED TO DATE $ ___________________
LESS ____________% RETAINED $ ___________________
NET AMOUNT EARNED $ ___________________
AMOUNT OF ORIGINAL CONTRACT $ ___________________
EXTRAS TO CONTRACT $ ___________________
TOTAL CONTRACT AND EXTRAS $ ___________________
CREDITS TO CONTRACT $ ___________________
ADJUSTED TOTAL CONTRACT $ ___________________
NET PREVIOUSLY PAID $ ___________________
NET AMOUNT OF THIS PAYMENT $ ___________________
BALANCE TO BECOME DUE (Inc. Retention) $ ___________________
It is understood that the total amount paid to date plus the amount requested in this application shall not exceed _______% of the cost of work
completed to date
.
I agree to furnish
Waivers of Lien for all materials under my contract when demanded.
SIGNED ______________________________________________ POSITION _____________________________________________________
Sub
scribed and sworn to before me this __________________________ day of ______________________ , ____________
SEAL:
_____________________________________________________________
N
otary Public
The above sworn statement should be obtained by the owner before each and every payment.
