RD 1927-5 Affidavit Regarding Work of Improvement

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Position 5

USDA

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

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AFFIDAVIT REGARDING WORK OF IMPROVEMENT

STATE OF

FORM APPROVED
OMB NO. 0575-0147
Exp. Date: MM/DD/YY

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:

1.
No construction, work of improvement, repair, or remodeling has been commenced or completed upon the property
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'')
3.
No claims or demands for payments have been made upon owner by any subcontractor or material supplier in
connection with any alleged construction or work of improvement, repair or remodeling.

Sworn and subscribed before me this

day of

I

(NOTARIAL SEAL)
(Notary Public)

My commission expires

Residing at

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply
with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid
OMB Control Number. The OMB Control Number for this information collection is 0575-0147. Public reporting for this collection of information is
estimated to be approximately 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are voluntary.
However, in order to obtain or retain a benefit, the information in this form is required under 7 CFR 1927-B, Real Estate Title Clearance and Loan
Closing. Rural Development has no plans to publish information collected under the provisions of this program. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer,
Rural Development Innovation Center, Regulations Management Division at ICRMTRequests@usda.gov

RD 1927-5 (Rev. 11-99)
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