_____________________________________being duly sworn, says that he/she is ________________________of

___________________________________________________ the (Sub-Original)contractor having a contract with

______________________________________________________the____________________________________

______________________________________________________for____________________________________

a _____________________________________situated on or around or in front of the following described property

in ___________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

whereof________________________________________________________was the owner, part owner or lessee.

SUB-CONTRACTOR:

Affiant further states that the following shows the names and addresses of every sub-contractor in the employ of said ____________________________________giving the amount, if any, which is due, or to become due, to them, or any of them, for work done, or machinery, material or fuel furnished to date hereof, under said contracts. *NOTE: This statement must be accompanied by a similar sworn statement signed by the sub-contractors listed below.

NAME	ADDRESS	TRADE	Amount due or to become due for work and materials to date hereof

MATERIAL MEN:

Said affiant further says that the following shows the names and addresses of every person furnishing machinery, material or fuel to ___________________________________giving the amount, if any, which is due, or to become due, to them, or any of them, for machinery, material or fuel furnished to date hereof, under said contracts.

NAME	ADDRESS	TRADE	Amount due or to become due for material furnished to date hereof

* NOTE: The above must be accompanied by "Certificate of Material man." In lieu of such certification, there may be furnished a written waiver of lien, a written release or receipt.