Fill Your Michigan Sworn Statement Template

The Michigan Sworn Statement form serves as a crucial document in the construction industry, ensuring that all parties involved in a public works project are paid for their contributions. This form is typically completed by contractors, subcontractors, or suppliers to declare their payment status and to confirm that the project is free from any claims or liens. Understanding the requirements and implications of this form is essential for maintaining transparency and accountability in construction projects across Michigan.

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Documents used along the form

When completing the Michigan Sworn Statement form, several other documents may also be necessary to ensure compliance and clarity in financial transactions related to public works projects. Below are four commonly used forms that complement the Sworn Statement.

Full Conditional Waiver: This document confirms that a contractor or supplier has been fully paid for their work or materials provided under a specific contract. It waives any rights to pursue further payment under a payment bond, provided that the payment has been received. This waiver is conditional upon the receipt of the specified payment amount.
Bill of Sale: This form is essential for documenting the transfer of ownership of personal property and can be conveniently accessed at Illinois PDF Forms.
Notice of Lien Claim: This form is filed by a contractor or supplier to formally notify the property owner or general contractor of a claim for unpaid work or materials. It serves as a warning that a lien may be placed on the property if payment is not made, thus protecting the rights of those who contributed to the project.
Payment Bond: A payment bond is a guarantee that a contractor will pay all subcontractors and suppliers for their work on a project. This document is often required in public works contracts to ensure that funds are available to cover all labor and materials, thus protecting the interests of all parties involved.
Subcontractor Agreement: This agreement outlines the terms between a contractor and a subcontractor regarding the scope of work, payment terms, and responsibilities. It helps clarify the relationship and obligations of each party, ensuring that everyone understands their roles in the project.

These documents work together to provide a clear framework for financial transactions and responsibilities in public works projects. It is essential to ensure that all necessary forms are completed accurately to avoid potential disputes and ensure compliance with legal requirements.

Michigan Sworn Statement Preview

		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

Similar forms

Affidavit: Similar to the Michigan Sworn Statement, an affidavit is a written declaration made under oath. Both documents require the signer to attest to the truthfulness of the information provided, making them legally binding.
Mechanic's Lien Waiver: This document is often used in construction projects to waive the right to file a mechanic's lien. Like the Sworn Statement, it confirms that payments have been made to subcontractors and suppliers, ensuring that the project is free from claims.
Payment Bond: A payment bond guarantees that subcontractors and suppliers will be paid for their work. The Michigan Sworn Statement serves a similar purpose by detailing amounts owed to these parties, thus protecting the interests of the project owner.
Release of Lien: This document formally releases a lien on property once payment has been made. The Sworn Statement also addresses payment issues, ensuring that all parties are aware of any outstanding amounts before work continues.
Contractor's Statement of Compliance: This statement verifies that a contractor has complied with all contractual obligations. Both documents help maintain transparency and accountability in financial transactions within a project.
Subcontractor Agreement: This agreement outlines the terms between a contractor and subcontractor. Similar to the Sworn Statement, it includes payment details and responsibilities, ensuring all parties understand their obligations.
Affidavit of Gift: When considering gifts of valuable property, utilizing the legal Affidavit of Gift document can help ensure a smooth transfer of ownership and protect against potential disputes.
Supplier Agreement: This document outlines the terms of supply for materials. Like the Sworn Statement, it includes payment terms and ensures that all suppliers are acknowledged in the payment process.
Invoice: An invoice details the amounts owed for services or materials provided. The Michigan Sworn Statement similarly lists amounts due to subcontractors and laborers, making it a vital document for financial clarity.
Construction Contract: This is a formal agreement between parties involved in a construction project. The Sworn Statement complements this by providing a sworn account of payments due and work completed.
Notarized Statement: A notarized statement is a declaration made in the presence of a notary public. The Michigan Sworn Statement also requires notarization, adding a layer of authenticity and legal weight to the information provided.

Misconceptions

Understanding the Michigan Sworn Statement form can be challenging, and several misconceptions can lead to confusion. Here are eight common misconceptions:

It is only for contractors. Many believe the form is exclusively for contractors. In reality, subcontractors and suppliers also use it to document their claims for payment.
It guarantees payment. Some think that submitting the sworn statement ensures they will receive payment. However, it merely provides a record of unpaid amounts; actual payment depends on other factors.
Only one form is needed for multiple projects. It’s a common misunderstanding that one form can cover several projects. Each project requires a separate sworn statement to accurately reflect the specific details and claims.
It can be submitted after payment is received. Many assume they can file the sworn statement after getting paid. However, it should be submitted before or at the time of requesting payment to maintain its validity.
All information is optional. Some people think they can leave out details. Every section of the form is important and should be filled out completely to avoid complications.
It’s only relevant for public works projects. While it is often associated with public works, the sworn statement can also be used in private contracts where similar payment protections are needed.
Notarization is unnecessary. Some believe they can submit the form without a notary. However, notarization is a critical step that verifies the identity of the signer and the authenticity of the statement.
It can be modified freely. There is a misconception that the sworn statement can be changed at will. The form must adhere to specific legal requirements, and any alterations could invalidate it.

Being aware of these misconceptions can help ensure that the Michigan Sworn Statement form is used correctly and effectively. Proper understanding can lead to smoother transactions and fewer disputes.

Detailed Instructions for Using Michigan Sworn Statement

After gathering the necessary information, you are ready to fill out the Michigan Sworn Statement form. This document requires accurate details about your company and any subcontractors or suppliers involved in a public works project. Follow these steps to ensure that you complete the form correctly.

Begin by entering the name of the person signing the sworn statement at the top of the form.
In the next blank, write the name of your company.
Select one of the options: contractor, subcontractor, or supplier, and write it in the designated space.
Specify the county where the public works project is located.
Provide the contract number in the appropriate field.
Fill in the project name for the public works project.
List each subcontractor, supplier, or laborer in the table provided. For each entry, include the following details:

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

After listing all relevant parties, calculate the subtotals for each category and enter them in the designated areas.
Finally, confirm that you have not procured materials or subcontracted with anyone not listed on the form. Check the appropriate box to indicate your compliance.
Sign the form as the contractor, subcontractor, or supplier, or as an authorized agent if applicable.
Have the statement notarized by a Notary Public, who will fill in their details and commission expiration date.

Once completed, the form should be submitted to the appropriate parties involved in the public works project. Ensure that all information is accurate and that the document is properly signed and notarized to avoid any issues. This will help maintain transparency and protect your rights under the contract.

Dos and Don'ts

When filling out the Michigan Sworn Statement form, keep these important tips in mind:

Do ensure all names and titles are correctly spelled and accurately reflect the individuals involved.
Do clearly indicate whether you are the contractor, subcontractor, or supplier.
Do provide complete and accurate information about the project, including the contract number and project name.
Do list all subcontractors and suppliers, along with the amounts owed to each.
Don't omit any necessary details about payments or withholdings due to laborers.
Don't forget to sign and date the form in the designated area.
Don't leave any sections blank; incomplete forms may lead to delays.
Don't provide false information, as this can result in serious legal consequences.

Fill Your Michigan Sworn Statement Template

Documents used along the form

Michigan Sworn Statement Preview

Similar forms

More PDF Documents

Misconceptions

Detailed Instructions for Using Michigan Sworn Statement

Dos and Don'ts