Title Insurance Company 

TO: 

Company 

Property Address: 

The undersigned owner of the above property, does under oath depose and say that: 

1. There is no person for whom a debt is due for labor or materials furnished in the erection, alteration, repair or removal of a building or structure or other improvement or alteration upon said property by virtue of an agreement with, or by the consent of the undersigned, or of a person having authority from or rightfully acting for the undersigned in performing or furnishing such labor or materials for work actually performed during the past 93 days, including the date hereof. 

2. At the date hereof, there are no tenants or other parties who are in possession or who have the right to be in possession of said property (except as shown below): 

3. All bills for municipal light plant service charges which could become liens have been paid. 

4. No security interest which secures payment or the performance of any obligation has been given by the undersigned, or to the knowledge of the undersigned, in any personal property or fixtures placed upon or installed in said property. 

This affidavit is made for the purpose of inducing the Title Insurance Company to insure the mortgage on said property, and the undersigned agrees to indemnify and hold harmless the Title Insurance Company from any loss resulting from reliance upon the truth and accuracy of the statements contained herein. 

Signed under the penalties of perjury this         day of        , 20  .