(2) that the following is a statement of each subcontractor and supplier and laborer, for which laborerer the payment of wages or fringe benefits and witholdings is due but unpaid, with whom the (contractor) (subcontractor) has (contracted) (subcontracted) for performance under the contract with the owner or lessee thereof, and that the amounts due to the persons as of the date thereof are correctly and fully set forth opposite their names, as follows.

(3) that the contractor has not procured materials from, or subcontracted with, any person other than those set forth above and owes no money for the improvement other than the sums set forth above. (4) deponent further says that he or she makes the forgoing statement as the (contractor)(subcontractor) or as an agent of the (contractor)(subcontractor) for the purpose of representing to the owner or lessee of the above-described premises and his or her agents that the above-described property is free from claims of construction liens, or the possibility of construction liens, except as specifically set forth above, and except for claims of constrction liens by laborers which may be provided pursuant to section 109 of the construction lien act, act no. 497 of the public acts of 1980, as amended, being section 570.1109 of the michigan compiled laws.

warning to owner: an owner or lessee of the above-described property may not rely on this sworn statement to avoid the claim of a subcontractor, supplier, or laborer who has provided a notice of furnishing or a laborer who may provde a notice of furnishing pursuant to section 109 of the construction lien act to the designee or to the owner or lessee if the designee is not named or has died.

warning to deponent: a person, who with intent to defraud, gives a false sworn statement is subject to criminal penalty as provided in section 110 of the construction lien act, act. no. 497 of the public acts of 1980, as amended, being sec 570.1110 of the michigan compiled laws.

________________________________________________________________ DATED:_______________
Deponent (Builder)

by ___________________________________

Notary Public __________________, Michigan

My commission expires: ________________