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Free Michigan Sworn Statement Template in PDF

The Michigan Sworn Statement form is a legal document used in the state of Michigan to affirm the status of contractors, subcontractors, and suppliers involved in public works projects. This form requires the signer to declare that all payments due to laborers and suppliers have been accurately reported and that no additional claims exist beyond what is specified. By signing this document, the individual certifies the accuracy of the information provided and acknowledges the legal implications of submitting false statements.

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Structure

The Michigan Sworn Statement form plays a crucial role in ensuring transparency and accountability in construction projects. This form is utilized by contractors, subcontractors, and suppliers to declare their financial obligations related to public works improvements. It outlines the parties involved, including subcontractors and laborers, and details the amounts owed for work performed or materials supplied. Each entry must accurately reflect the total contract amount, payments made, and any outstanding balances. By signing this document, the contractor or authorized representative certifies that there are no undisclosed claims against the project, thus protecting all parties involved from potential liens. Additionally, the form includes a warning about the legal consequences of providing false information, emphasizing the importance of honesty in financial reporting. Overall, the Michigan Sworn Statement serves as a vital tool for maintaining trust and clarity in construction transactions.

Form Example

		SWORN STATEMENT
STATE OF MICHIGAN		)
		) ss.
COUNTY OF		)

<<<name of person signing sworn statement>>>, being duly sworn, deposes and says: That <<<name of company>>> is a/the <<<select one>>>(contractor)(subcontractor)(supplier) for an improvement to the following described public works situated in __________ County, Michigan, described as follows:

Contract No. <<<MDOT Contract ID Number>>> Project Name: <<<eg. I-96 from U.S 23 to Kent Road>>>

That the following is a statement of each subcontractor and supplier and laborer, for which laborer the payment of wages or fringe benefits and withholdings is due but unpaid, with whom the <<<same selection as above>>>(contractor)(subcontractor)(supplier) has <<<select one>>>(contracted)(subcontracted)(supplied material)(supplied labor) for performance under the contract with the owner, lessee, or general contractor thereof, and that the amounts due to the persons as of the date hereof are correctly and fully set forth opposite their names, as follows:

Name of Subcontractor,	Type of	Total	Amount	Amount	Balance	Amount of		Amount of Laborer
Supplier, or Laborer	Improvement Furnished	Contract	Already	Currently	to	Laborer	Retention	Fringe Benefits
		Price	Paid	Owing	Complete	Wages Due		and Withholdings
						But Unpaid		Due But Unpaid

SUB TOTALS

Name of Subcontractor,	Type of	Total	Amount	Amount	Balance	Amount of		Amount of Laborer
Supplier, or Laborer	Improvement Furnished	Contract	Already	Currently	to	Laborer		Fringe Benefits
		Price	Paid	Owing	Complete	Wages Due	Retention	and Withholdings
						But Unpaid		Due But Unpaid











	TOTALS

That the (contractor) (subcontractor) has not procured material from, or subcontracted with, any person other than those set forth on the reverse side and owes no money for the improvement other than the sums set forth on the reverse side.

Deponent further says that he or she makes the foregoing statement as the (contractor)(subcontractor)(supplier) or as <<<authorized agent if signator is not officer or employee of company>>> of the (contractor)(subcontractor)(supplier) for the purposes of representing to the owner, lessee, or general contractor of the public works described on the reverse side and his or her agents that the public works described on the reverse side is free from claims of construction or bond liens, or the possibility of construction or bond liens, except as specially set forth on the reverse side hereof..

WARNING TO DEPONENT: A PERSON, WHO WITH INTENT TO DEFRAUD, GIVES A FALSE SWORN STATEMENT FOR THE PURPOSE OF OBTAINING PAYMENT IS SUBJECT TO CRIMINAL and CIIVIL PENALTIES AS PROVIDED BY LAW.

(Deponent)


Subscribed and sworn to before me this				day of
			, 20___.
		, Notary Public
	County, Michigan
My commission expires:
Acting in _______________ County

91742v2

					SWORN STATEMENT
STATE OF MICHIGAN		)
			) ss.
COUNTY OF		)
	__________________		, being duly sworn, deposes and says: That ______________________			is a/the (contractor)(subcontractor)(supplier) for an improvement to

the following described public works situated in _______ County, Michigan, described as follows:

Contract No.				; Project Name:

That the following is a statement of each subcontractor and supplier and laborer, for which laborer the payment of wages or fringe benefits and withholdings is due but unpaid, with whom the (contractor)(subcontractor)(supplier) has (contracted)(subcontracted)(supplied material)(supplied labor) for the improvement on the above referenced public works project and that the amounts due to the persons as of the date hereof are correctly and fully set forth opposite their names, as follows:

Name of Subcontractor,	Type of	Total	Amount	Amount	Balance	Amount of		Amount of Laborer
Supplier, or Laborer	Improvement Furnished	Contract	Already	Currently	to	Laborer	Retention	Fringe Benefits
		Price	Paid	Owing	Complete	Wages Due		and Withholdings
						But Unpaid		Due But Unpaid

SUB TOTALS

Name of Subcontractor,	Type of	Total	Amount	Amount	Balance	Amount of		Amount of Laborer
Supplier, or Laborer	Improvement Furnished	Contract	Already	Currently	to	Laborer		Fringe Benefits
		Price	Paid	Owing	Complete	Wages Due	Retention	and Withholdings
						But Unpaid		Due But Unpaid











	TOTALS

Deponent further says that he or she makes the foregoing statement as the (contractor)(subcontractor)(supplier) or as _____ ____ of the (contractor)(subcontractor)(supplier) for

the purposes of representing to the party from whom payment is requested and to the prime contractor who has furnished a payment bond covering the public works project described on the reverse side and his or her agents that the public works described on the reverse side is free from claims of payment bond liens, or the possibility of payment bond liens, except as specially set forth on the reverse side hereof.

WARNING TO DEPONENT: A PERSON, WHO WITH INTENT TO DEFRAUD, GIVES A FALSE SWORN STATEMENT FOR THE PURPOSE OF OBTAINING PAYMENT IS SUBJECT TO CRIMINAL and CIIVIL PENALTIES AS PROVIDED BY LAW.

(Deponent)


Subscribed and sworn to before me this				day of
			, 20___.
		, Notary Public
	County, Michigan
My commission expires:
Acting in _______________ County

91742

FULL CONDITIONAL WAIVER

Our contract with <<<name of company>>> to furnish<<<general description of

work/material furnished. Eg. Concrete work and related items. Eg. Aggregate

materials>>> materials to <<<MDOT>>> Project No. <<<MDOT Contract ID

Number>>> has been fully paid and satisfied with respect to our rights under the Payment / Lien Bond covering said Project and all of our rights to pursue payment under the Payment/Lien Bond No. _____________ issued by <<<name of prime

contractor>>> as principal and <<<name of payment bond surety>>> as surety,

together with any rights, demands, or causes of action we may have against _<<<name

of prime contractor>>> or <<<name of payment bond surety>>>, are hereby fully waived and released and the “Notice of Lien Claim” (if any) dated ,<<<insert “N/A” if none. Insert date of Notice of Lien Claim if one has been filed>>> and any amendment(s) thereto, is hereby rescinded.

This waiver is	conditioned upon our receipt of payment in the amount of
$<<<amount of payment for which waiver is being given>>>
	<TYPE OR PRINT COMPANY NAME>
	__________________________
	by:	<<type or print name>>
	its:	<<type or print title>>
STATE OF MICHIGAN	)
	) SS
COUNTY OF	)

The signator is known to me and acknowledged the foregoing instrument this

___ day of ________, 20___.

________________________________

____________________, Notary Public

_____________County, Michigan

My commission expires: ___________

Acting In _____________ County

91748v2

FULL CONDITIONAL WAIVER

Our contract with _________________ to furnish ______________________

materials to _______ Project No. _____________ has been fully paid and satisfied with

respect to our rights under the Payment / Lien Bond covering said Project and all of our rights to pursue payment under the Payment/Lien Bond No. _____________ issued by

_______________________ as principal and ____________________ as surety,

together with any rights, demands, or causes of action we may have against

_____________________ or __________________ , are hereby fully waived and

released and the “Notice of Lien Claim” (if any) dated _______________, and any

amendment(s) thereto, is hereby rescinded.

	This waiver		is	conditioned upon our receipt of payment in the amount of
$		.
				___________________________
				__________________________
				by:	_____________________
				its:	_____________________
STATE OF MICHIGAN				)
				) SS
COUNTY OF				)

The signator is known to me and acknowledged the foregoing instrument this

___ day of ________, 20___.

________________________________

____________________, Notary Public

_____________County, Michigan

My commission expires: ___________

Acting In _____________ County

91748

FULL UNCONDITIONAL WAIVER

Our contract with <<<name of company>>> to furnish general description of work/material furnished. Eg. Concrete work and related items. Eg. Aggregate

materials>>>	materials to <<<MDOT>>> Project No. <<<MDOT Contract ID
Number>>>	has been fully paid and satisfied with respect to our rights under the

Payment / Lien Bond covering said Project and all of our rights to pursue payment under the Payment/Lien Bond No. _____________ issued by <<<name of prime

contractor>>> as principal and <<<name of payment bond surety>>> as surety, together with any rights, demands, or causes of action we may have against <<<name

of prime contractor>>> or <<<name of payment bond surety>>> , are hereby fully waived and released and the “Notice of Lien Claim” (if any) dated ,<<<insert “N/A” if none. Insert date of Notice of Lien Claim if one has been filed>>>, and any amendment(s) thereto, is hereby rescinded.

	<TYPE OR PRINT COMPANY NAME>
	__________________________
	by: <<type or print name>>
	its: <<type or print title>>
STATE OF MICHIGAN	)
	) SS
COUNTY OF	)

The signator is known to me and acknowledged the foregoing instrument this

___ day of ___________, 20___.

________________________________

Notary Public

_____________County, Michigan

My commission expires: ___________

Acting In _____________ County

91747v2

FULL UNCONDITIONAL WAIVER

Our contract with _________________ to furnish ______________________

materials to ______ Project No._________________ has been fully paid and satisfied

with respect to our rights under the Payment / Lien Bond covering said Project and all of our rights to pursue payment under the Payment/Lien Bond No. _____________ issued

by _______________________ as principal and ____________________ as surety,

together with any rights, demands, or causes of action we may have against

_____________________ or __________________ , are hereby fully waived and

released and the “Notice of Lien Claim” (if any) dated _______________, and any

amendment(s) thereto, is hereby rescinded.

	___________________________
	__________________________
	by:
	its:
STATE OF MICHIGAN	)
	) SS
COUNTY OF	)

The signator is known to me and acknowledged the foregoing instrument this

___ day of ___________, 20___.

________________________________

Notary Public

_____________County, Michigan

My commission expires: ___________

Acting In _____________ County

91747

PARTIAL CONDITIONAL WAIVER OF LIEN

Our contract with <<<name of company>>> to furnish <<<general description of work/material furnished. Eg. Concrete work and related items. Eg. Aggregate

materials>>>to <<<MDOT>>> Project No. <<<MDOT Contract ID Number>>> has

been partially paid and satisfied in the amount of $<<<amount of payment for which waiver is being given>>>with respect to our rights under the Payment / Lien Bond covering said Project and our rights to pursue payment under the Payment/Lien Bond

No.issued by <<<name of prime contractor>>> as principal and

<<<name of payment bond surety>>> as surety, together with any rights, demands, or causes of action we may have against <<<name of prime contractor>>> or <<<name

of payment bond surety>>> are hereby waived and released to the extent of said partial payment of $ <<<amount of payment for which waver is being given>>> and the “Notice of Lien Claim” (if any) dated ,<<<insert “N/A” if none. Insert date of Notice of Lien Claim if one has been filed>>> and any subsequent amendment(s) thereto, are hereby rescinded, waived and released for the amount of $ <<<amount of payment for which waiver is being given>>> and are hereby amended to reflect only the remaining balance claimed to be due under our contract in the amount of $<<<remaining balance after deduction of all partial payments to date>>>.

This waiver is conditioned upon our receipt of payment in the amount of

$<<<amount of payment for which waver is being given>>>

	<TYPE OR PRINT COMPANY NAME>
	______________________________
	by:	<<type or print name>>
	its:	<<type or print title>>
STATE OF MICHIGAN	)
	) SS
COUNTY OF	)

The signator is known to me and acknowledged the foregoing instrument this

___ day of ________, 20___.

________________________________

____________________, Notary Public

_____________County, Michigan

My commission expires: ___________

Acting In _____________ County

91744v2

PARTIAL CONDITIONAL WAIVER OF LIEN

Our contract with ___________________________ to furnish _____________,

__________________________________ to _________________________ Project

No. _________________________________ has been partially paid and satisfied in

the amount of $___________with respect to our rights under the Payment / Lien Bond

covering said Project and our rights to pursue payment under the Payment/Lien Bond No. _____________ issued by ____________________________ as principal and

____________________________ as surety, together with any rights, demands, or

causes of action we may have against __________________________ or

_______________________________________ are hereby waived and released to the

extent of said partial payment of $_________ and the “Notice of Lien Claim” (if any)

dated _________________________, and any subsequent amendment(s) thereto, are

hereby rescinded, waived and released for the amount of $____________ and are

hereby amended to reflect only the remaining balance claimed to be due under our

contract in the amount of $___________.

	This waiver	is	conditioned upon our receipt of payment in the amount of
$		.
			______________________________
			______________________________
			by:
			its:
STATE OF MICHIGAN			)
			) SS
COUNTY OF			)

The signator is known to me and acknowledged the foregoing instrument this

___ day of ________, 20___.

________________________________

____________________, Notary Public

_____________County, Michigan

My commission expires: ___________

Acting In _____________ County

91744

▼ Michigan Sworn Statement PDF Form

Document Specs

Fact Name	Description
Purpose	The Michigan Sworn Statement form is used to provide a detailed account of unpaid wages, fringe benefits, and withholdings owed to subcontractors, suppliers, and laborers involved in public works projects.
Governing Law	This form is governed by Michigan's Construction Lien Act (Public Act 497 of 1980), which outlines the rights and responsibilities related to construction liens and payments.
Affidavit Requirement	The individual signing the form must be duly sworn, affirming that the information provided is accurate and truthful.
Potential Penalties	Providing false information on the sworn statement can result in both criminal and civil penalties, emphasizing the importance of honesty in the declaration.
Contractor Identification	The form requires the identification of the contractor, subcontractor, or supplier, along with the specific public works project they are associated with.
Payment Details	It includes a breakdown of amounts owed to each laborer or supplier, detailing total amounts, payments made, and any outstanding balances.
Notary Public	A notary public must witness the signing of the form, adding a layer of verification to the document's legitimacy.

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