REQUEST BY OWNER 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 LIEN.

TO:	________________________________

(Lienor's Name)

________________________________

________________________________

(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 accounts to date, the amount due, and the amount to become due for the improvement of real property identified as (legal description):

Dated: __________________,	.

Owner

By:

Print Name:

Print Title:

Address: