44-Doc 00 65 19.13 - CONTRACTORS AFFIDAVIT.pdf

CONTRACTOR'S AFFIDAVIT

00 65 19.13-1

DOCUMENT 00 65 19.13

CONTRACTOR'S AFFIDAVIT

STATE OF______________________________:

COUNTY OF ____________________________:

Before me, the undersigned, a Notary Public in and for said County and State personally appeared

(Individual/Partner/Duly Authorized Representative of Corporate Contractor) who being duly sworn according to law deposes and says that all labor, material and outstanding claims and indebtedness of whatever nature arising out of the performance of the Work including all approved change orders under an Agreement dated __________________________, 20___________ associated with

Contract #25-00014: Bristol Borough 2025 CDBG Design/Build Curb Ramp Project Between

Bristol Borough, 250 Pond Street, Bristol, PA 19007 (Owner, Name and Address) and (Contractor, Name and Address) have been satisfied and paid in full.

CONTRACTOR

Company:

(Corp. Seal) Signature:_________________________________ (Individual, Partner or Duly Authorized Representative of Corporate Contractor)

Name and Title:

Sworn and subscribed before me this

_____day of ________________,20___.

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