The Michigan Sworn Statement form is a legal document used to affirm the payment status of subcontractors, suppliers, and laborers involved in public works projects. This form serves to protect all parties by ensuring that claims for unpaid wages or benefits are accurately reported. If you need to complete this important form, please click the button below to get started.
The Michigan Sworn Statement form is a crucial document in the construction industry, particularly for public works projects. It serves as a formal declaration by contractors, subcontractors, or suppliers regarding their financial obligations related to labor and materials. This form outlines the specific project details, including the contract number and project name, and provides a comprehensive list of all subcontractors, suppliers, and laborers involved. Each entry details the total amount owed, amounts already paid, and any outstanding balances for wages, fringe benefits, and withholdings. By signing this document, the deponent asserts that no other financial obligations exist beyond those listed, ensuring transparency and accountability. Additionally, the form includes a warning about the legal repercussions of providing false information, emphasizing the importance of accuracy in these statements. Ultimately, the Michigan Sworn Statement form helps protect all parties involved by clarifying payment responsibilities and safeguarding against potential lien claims.
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
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
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
__________________
, 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:
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.
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>>
) SS
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
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
$
.
___________________________
_____________________
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.
by: <<type or print name>>
its: <<type or print title>>
___ day of ___________, 20___.
Notary Public
91747v2
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,
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>>>
______________________________
91744v2
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 $___________.
91744
Completing the Michigan Sworn Statement form is an important step in ensuring that all parties involved in a public works project are properly compensated. After filling out the form, it will need to be signed in the presence of a notary public. This process verifies the authenticity of the information provided and ensures compliance with legal requirements.
The Michigan Sworn Statement form is a legal document used primarily in construction and public works projects. It serves to confirm that a contractor, subcontractor, or supplier has paid their laborers and suppliers for work performed. The form helps protect the interests of all parties involved by ensuring that there are no outstanding claims or liens against the project.
Typically, the contractor, subcontractor, or supplier involved in a public works project is required to complete this form. It is essential for anyone who is seeking payment for their services or materials provided in relation to the project. The person signing the form must have the authority to do so on behalf of their company.
The form requires several key pieces of information, including:
Providing false information on the Michigan Sworn Statement can lead to serious consequences. If a person knowingly submits a false sworn statement with the intent to defraud, they may face both criminal and civil penalties as outlined by law. This underscores the importance of accuracy and honesty when completing the form.
Yes, the form must be signed in front of a notary public. The notary's role is to verify the identity of the person signing the document and to ensure that the statement is made under oath. This adds a layer of authenticity and legal weight to the sworn statement.
The Michigan Sworn Statement is specifically designed for public works projects. While similar forms may exist for private contracts, this particular document is tailored to meet the requirements of public contracts and the associated laws governing them.
The amounts listed on the Michigan Sworn Statement reflect the total payments owed to subcontractors, suppliers, and laborers as of the date of signing. This information is crucial for ensuring that all parties are paid appropriately and that there are no outstanding debts that could lead to liens against the project.
The sworn statement acts as a declaration that the project is free from claims of construction or bond liens, except for those specifically noted on the form. By providing this statement, the contractor or supplier assures the owner and general contractor that they have settled their financial obligations, thus reducing the risk of future claims against the project.
If you have questions about how to complete the Michigan Sworn Statement, it’s advisable to consult with a legal professional who specializes in construction law. They can provide guidance tailored to your specific situation and ensure that you comply with all legal requirements.
The Michigan Sworn Statement form can typically be obtained from the Michigan Department of Transportation (MDOT) website or through legal document services. Additionally, many law offices that specialize in construction law may have copies available. Ensure you are using the most current version of the form to meet legal standards.
Incomplete Information: One common mistake is failing to provide all necessary details. For example, leaving out the name of the company, the contract number, or the project name can lead to confusion and delays. Each section of the form must be filled out completely to ensure clarity.
Incorrect Selection: The form requires individuals to select between contractor, subcontractor, or supplier. Choosing the wrong designation can have serious implications for liability and payment responsibilities. It is essential to carefully consider which role applies to the individual or entity filling out the form.
Failure to List All Parties: Not including all subcontractors, suppliers, and laborers involved in the project is another frequent error. This omission can result in legal challenges or disputes regarding payment. Ensure that everyone who has contributed to the project is accounted for on the form.
Inaccurate Financial Figures: Providing incorrect amounts for payments due can lead to significant issues. It is crucial to double-check all financial figures, including total amounts, balances, and any withholdings. Accuracy in this section is vital to avoid potential legal repercussions.
Not Swearing Before a Notary: The final step of the process requires the individual to be sworn in before a notary public. Skipping this step or failing to have the document notarized renders the sworn statement invalid. Always ensure that this important step is completed to uphold the document's integrity.
The Michigan Sworn Statement form is a crucial document used in construction and public works projects to ensure transparency and accountability among contractors, subcontractors, and suppliers. Alongside this form, several other documents are often utilized to provide a comprehensive overview of financial obligations and project statuses. Below is a list of these documents, each serving a specific purpose in the contracting process.
These documents work together to create a clear and organized framework for managing construction projects. Each serves a distinct role in ensuring that all parties are protected and that the project proceeds smoothly. Understanding these documents is essential for anyone involved in the contracting process.
The Michigan Affidavit of Payment is similar to the Michigan Sworn Statement form in that both documents serve to confirm the payment status of subcontractors and suppliers involved in a construction project. The affidavit requires the contractor or subcontractor to declare under oath that they have paid all parties for their work, thereby providing assurance to the project owner that there are no outstanding claims. Just like the Sworn Statement, it includes a detailed list of all parties involved and the amounts due, ensuring transparency in financial transactions related to the project.
Another document akin to the Michigan Sworn Statement is the Conditional Waiver and Release of Lien. This form allows a contractor or supplier to waive their right to file a lien on a property, contingent upon receiving payment. Similar to the Sworn Statement, it requires a declaration under oath, ensuring that the contractor has fulfilled their financial obligations to subcontractors and suppliers. Both documents aim to protect the interests of all parties involved by clarifying payment statuses and potential claims against the property.
The Michigan Release of Lien is also comparable to the Michigan Sworn Statement form. This document is used to officially release any claims against a property once payment has been received. Like the Sworn Statement, it serves as a safeguard for property owners by confirming that all contractors and subcontractors have been compensated. The release helps to eliminate the risk of future claims or liens, thereby ensuring a clear title for the property.
Another related document is the Payment Bond Claim Form, which is used when a contractor seeks payment under a bond that guarantees payment to subcontractors and suppliers. This form requires a detailed account of the work performed and the amounts owed, much like the Michigan Sworn Statement. Both documents provide a mechanism for ensuring that all parties are compensated fairly and that the project proceeds without financial disputes.
Lastly, the Michigan Notice of Intent to Lien shares similarities with the Michigan Sworn Statement. This document serves as a warning to property owners that a contractor or supplier intends to file a lien if payment is not received. While the Sworn Statement focuses on confirming payment status, the Notice of Intent highlights potential claims. Both documents are essential tools for contractors and suppliers to communicate their payment rights and obligations, fostering transparency in construction projects.
When filling out the Michigan Sworn Statement form, consider the following dos and don’ts:
Misconceptions about the Michigan Sworn Statement form can lead to confusion and mistakes. Here are ten common misunderstandings:
Understanding these misconceptions can help ensure that the form is completed correctly and used effectively.
Filling out the Michigan Sworn Statement form is a crucial step in ensuring transparency and accountability in construction projects. Here are key takeaways to keep in mind:
By following these guidelines, you can navigate the Michigan Sworn Statement form with confidence and ensure compliance with state regulations.