Affidavit of Payment of Debts and Claims CAP706 Contract Date 12/27/2006 To Owner Contract for ACME BUILDING CORPORATION 12345 MAIN STREET ANYWHERE US 12345 CONTRUCTION THIRD FLOOR WORLD HEADQUARTERS Architect s Project Number Distribute To PEM CONSTRUCTION COMPANY P. Exceptions There are no Exceptions on this affidavit SAMPLE Attached Supporting Documents 1. Surety to Final Payment if required. Is document attached 2. If required by the Owner. Contractor s Release or Waiver of Liens. Separate Releases or Waivers of Liens from Subcontractors material and equipment suppliers 3. O. BOX 217 CLAYTON NC 27528 Project Architect Surety Other State of Sample Project 3RD FLOOR DEMOLITION AND RENOVATION North Carolina County of Default County Name This undersigned certifies that with the exceptions listed below payment has been made in full and all obligations have been satisifed for the following All Materials Equipment Work Labor Services and claims against the Contractor in connection with the above mentioned Contract. Exceptions There are no Exceptions on this affidavit SAMPLE Attached Supporting Documents 1. Surety to Final Payment if required. Is document attached 2. O. BOX 217 CLAYTON NC 27528 Project Architect Surety Other State of Sample Project 3RD FLOOR DEMOLITION AND RENOVATION North Carolina County of Default County Name This undersigned certifies that with the exceptions listed below payment has been made in full and all obligations have been satisifed for the following All Materials Equipment Work Labor Services and claims against the Contractor in connection with the above mentioned Contract. Exceptions There are no Exceptions on this affidavit SAMPLE Attached Supporting Documents 1. Surety to Final Payment if required* Is document attached 2. If required by the Owner. Contractor s Release or Waiver of Liens. Separate Releases or Waivers of Liens from Subcontractors material and equipment suppliers 3. Release of Liens Affidavit Subscribed and sworn to before me on this date Notary Public Default Notary Public My Commission Expires December 31 2010 Forms and Software by PEM Software Systems Inc* 1-800-803-1315 Copyright 2007 BY signature of authorized representative Printed Name and title. If required by the Owner. Contractor s Release or Waiver of Liens. Separate Releases or Waivers of Liens from Subcontractors material and equipment suppliers 3. Release of Liens Affidavit Subscribed and sworn to before me on this date Notary Public Default Notary Public My Commission Expires December 31 2010 Forms and Software by PEM Software Systems Inc* 1-800-803-1315 Copyright 2007 BY signature of authorized representative Printed Name and title.