Fillable Form 1: } ss. GREATER ILLINOIS TITLE COMPANY (Greater Illinois Title Company)

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Form 1: } ss. GREATER ILLINOIS TITLE COMPANY (Greater Illinois Title Company)

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Copyright ©2005 Greater Illinois Title Company. All Rights Reserved. http://gitc.com/forms/
Compliments of Greater Illinois Title Company; for Internal and External Use.
Unive
rsal Doc Ref: GP_IEF0026-20050804-R1-0
GREATER ILLINOIS TITLE COMPANY
SWORN OWNER'S STATEMENT TO GREATER ILLINOIS TITLE COMPANY
STATE OF ILLI
NOIS
Guarantee No. ________________
COU
NTY OF _________________________
} ss.
Escrow No. ___________________
The affiant, _____________________________________________________________________________ being first duly sworn, on oath deposes
and says
that he is the * owner/beneficiary of Trust No. ____________________ held by _______________________________________________
which is the owner * of the followin
g described premises in _______________________ County, Illinois, to wit: _____________________________
_____________________________________________________________________________________________________________________ .
1
. T
hat he is thoroughly familiar with all the facts and circumstances concerning the premises described above;
2. T
hat with respect to improvements on the premises the only work done or materials furnished to date are as listed below;
3. Tha
t the only contracts let for the furnishing of future work or materials relative to the contemplated improvements are as listed below;
4. T
hat this statement is a true and complete statement of all such contracts, previous payments and balances due, if any.
NAME AND ADDRESS K
IND OF WORK
ADJUSTED TOT
AL
CONTRACT
INC.
EXTRAS & CRED
ITS
PRE
VIOUSLY
PAID
A
MOUNT O
F
THIS
PAYM
ENT
BALANCE TO
B
ECOME
DUE
ARCHITECT
SURVEYOR
ENGINEER
SOIL TESTS
GENERAL
CONTRACTOR
OFF-SITE
IMPROVEMENTS
OTHERS
*STRIKE ONE* THE UNDERSIGNED HEREBY APPROVES THE ABOVE AMOUNTS FOR PAYMENT.
SIGNED ______________________________________________ ADDRESS _____________________________________________________
Sub
scribed and sworn to before me this __________________________ day of ______________________ , ____________
SEAL:
_____________________________________________________________
N
otary Public
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Form 1: ss. GREATER ILLINOIS TITLE COMPANY (Greater Illinois Title Company)

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Completed 13 August 2021

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