AFFIDAVIT OF PAYMENT - VIRGINIA
STATE OF ____________________________
COUNTY/CITY OF ____________________
The affiant ______________________________________, being duly sworn and on oath, deposes and says that he/she is ________________________________________ of ___________________________________________________________ which is the Owner of and Developer/Contractor in connection with the development/contractor or subcontractor furnishing labor or materials (eliminate inapplicable) in connection with the development or improvement of the property hereinafter described as follows:
1. That he/she is thoroughly familiar with all of the facts and circumstances concerning the property described above;
2. That all persons performing labor or furnishing materials in connection with the improvements on said property and with whom the owner, ________________________, is in privity of contract have been paid in full except for the following:
(IF NONE, STATE "NONE")
NAME AND ADDRESS AMOUNT PAYABLE OR CLAIMED TO BE PAYABLE
3. That this affidavit is given pursuant to the provisions of Section 43-13.2 of the Code of Virginia (1950 as amended) which requires this affidavit be furnished the purchaser of the aforesaid property.
4. That it is understood and agreed that any willful material misrepresentation with respect to this statement which causes a monetary loss to a financial institution, title company, contractor, sub-contractor, supplier, owner, mechanic's lien agent, or any other person or institution is punishable as a Class 5 felony.
Name of Affiant
Subscribed and sworn to before me this _____ day of ___________________, 20_____.
My Commission Expires: _________________
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