TENANT’S AFFIDAVIT OF PAYMENT



TENANT’S AFFIDAVIT OF PAYMENT

The undersigned, being a Tenant at (****) occupying the premises known as (DBA), hereby certifies to (_________________________________), Landlord, that Tenant’s Work is described per the Lease, has been completed satisfactorily, that all contractors, laborers and material suppliers have been paid in full and that no liens have been placed against said property. Tenant further agrees to indemnify and hold harmless the Landlord, from any claim or cause of action brought by Tenant’s contractor, subcontractors, laborers, and material suppliers, arising out of the construction of the above.

Affiant affirms that all payments made were used solely for real property improvements located in or on the premises and for no other purpose.

Affiant further says that the following shows the name of EVERY contractor or material supplier in the employ of said Tenant, for work done, machinery, material or fuel furnished to date hereof, as called for by Tenant’s plans and specifications for the Premises as approved by Landlord.

CONTRACTORS AND MATERIAL SUPPLIERS

NOTE - THIS STATEMENT MUST BE ACCOMPANIED BY A WAIVER OF LIEN (DENOTING FINAL PAYMENT) SIGNED BY EACH OF THE CONTRACTORS AND MATERIAL SUPPLIERS LISTED BELOW:

| |Service |Contract |Amount |This |Balance |

|Name |Rendered |Price |Paid |Payment |Due |

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|Total labor and materials | | | | | |

Affiant further states that the amounts due or to become due to said contractors, material men and laborers, for work done or machinery, material or fuel furnished to the date hereof are fully and correctly set forth opposite their names, respectively, in the aforesaid statements, and further evidence by Waiver of Liens of EVERY person furnishing machinery, material or fuel, hereto attached, and made a part hereof.

Affiant further states that all of Tenant’s Work in the premises has been fully completed to the satisfaction of the Tenant and in accordance with the provisions of said Lease.

IN WITNESS:

WHEREOF, the undersigned Tenant has caused the Affidavit of Payment to be executed by its duly authorized officer.

Signed this __________day of ___________________, 20______. By:_____________________________________________

(Officer/Title)

STATE OF )

) SS:

COUNTY OF )

SWORN TO AND SUBSCRIBED BEFORE ME THIS ____day of ___________, 20___. ___________________________________

(Notary Public)

My Commission Expires: ___________________________ Seal: ____________________________________

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