Rd 1927-5

Position 5

USDA

FORM APPROVED
OMB NO. 0575-0147

Form RD 1927-5
(Rev. 11-99)

AFFIDAVIT REGARDING WORK OF IMPROVEMENT
STATE OF
ss:
COUNTY OF
Before me, the undersigned authority, personally appeared

, personally known to me, who, being by me duly
sworn, depose and say, upon information and belief, that:
No construction, work of improvement, repair, or remodeling has been commenced or completed upon the property
1.
and no materials or services in connection therewith have been delivered to or performed on the property within the last
months, except:
(If none, write ''none'')
2.
If any construction, work of improvement, repair, or remodeling was commenced or completed or services in connection therewith were delivered to or performed on the property within the period set forth in paragraph 1, all costs,
charges and expenses incurred in connection therewith have been paid in full except:
(If none, write ''none'')
No claims or demands for payments have been made upon owner by any subcontractor or material supplier in
3.
connection with any alleged construction or work of improvement, repair or remodeling.

Sworn and subscribed before me this

day of

I

(NOTARIAL SEAL)
(Notary Pub1i c)

My commission expires

Residing at

According to the Paperwork Reduction Act of l995, an agency may not conductor sponsor, and a person is not required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0575-0147. The time required to complete this information collection
is estimated to average I 0 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.

RD 1927-5 (Rev. 11-99)