REQUEST BY CONTRACTOR FURNISHING BOND

FOR SWORN STATEMENT OF ACCOUNT

WARNING: YOUR FAILURE TO FURNISH THE REQUESTED STATEMENT SIGNED UNDER OATH WITHIN THIRTY (30) DAYS OR THE FURNISHING OF A FALSE STATEMENT WILL RESULT IN THE LOSS OF YOUR RIGHTS UNDER THE BOND.

TO:

(Lienor's Name or person designated in

Notice to Contractor)

________________________________

________________________________

(Lienor's Address)

The undersigned hereby demands a written statement, under oath, of his account showing the nature of the labor or services performed and to be performed, the materials furnished and to be furnished, the amount paid on account to date, the amount due, and the amount to become due for the real property described as (legal description):

Dated: ,	.

Contractor

By:

Print Name:

Print Title

Address: