VERIFIED STATEMENT OF ACCOUNT
RE: (Job Description)
STATE OF FLORIDA
COUNTY OF _________________
BEFORE ME, the undersigned authority, personally appeared ______________________, who after
being duly sworn deposes and says that:
He/She is the ___________________ of ___________________ the lienor.
As of ________________, 20 ______, ______, the amount due said lienor, for work done
at the subject project is the sum of $_____________,
3. The amount paid on the account to date is $ ___________________.
The amount yet to become due is estimated to be approximately $ _________________.
5. The nature of the labor or services performed is: ________________________________
The nature of the labor or services to be performed is: ___________________________
A description of the materials furnished is: _____________________________________
A description of the materials anticipated to be furnished is: _______________________
The foregoing instrument was sworn to or affirmed before me this ____ of __________, 20_____ ,
by _________________________________ who is personally known to me or who has produced
______________________ as identification and who did take an oath.
Prepared by: ______________________________________
NOTARY PLUBLIC, STATE OF ______________
My Commission Expires: __________________