Said affidavit further says that the following shows the names and addresses of every unpaid laborer in the employ of ________________________furnishing labor under said contract, giving the amount, if any, which is due, or to become due, for labor done to date hereof. *NOTE: If the fact is that every laborer has been paid in full, then recite "Every laborer has been paid in full." If not, then give each unpaid laborer(s) name and address and amount to become due."

NAME	ADDRESS	TRADE	HOURS	Amount due to become due for labor furnished to date hereof.

Affidavit further states that there is due or to become due to _____________________________ for work performed or machinery, material or fuel furnished to ______________________________to date hereof under said contracts, in the sum of $________________. ( Owner or Contractor)

That the amounts due or to become due to said sub-contractors, material men and laborers, for work done or machinery, material or fuel furnished to the date hereof to____________________________________________are fully and correctly set forth opposite their names, respectively, in the aforesaid statements, and further evidenced by certificates of every person furnishing machinery, material or fuel, hereto attached, and made a part hereof.

Affiant further states that___________________________________________ has not employed or purchased or procured machinery, material or fuel from, or sub-contracted with any person, firm or corporation, other than those above mentioned, and owes for no labor performed, or machinery, material or fuel furnished, under said contracts, other than above set forth.

________________________________________

SWORN TO BEFORE ME AND SUBSCRIBED IN MY PRESENCE, at ______________________________

This ______day of __________________20_______.

___________________________________________

(NOTARY PUBLIC)