B-210-13

Rev 04/03

AFFIDAVIT

The affiant,
(Company Representative)
(Company Name)
being duly sworn, states that he is the contractor
(for construction, demolition, renovation, restoration, material, etc.)
(Name and location of the project as described by your contract)
Designated as Contract Number	by the Department for Facilities Management of the
Commonwealth of Kentucky, that said contract, including all changes and additions thereto, has been
completed in accordance with the plans and specifications approved by the Division of Engineering, that
he will accept as full and final settlement payment in the amount of	$	which is based
on Final Invoice No.	. And that he hereby releases the Commonwealth of Kentucky from
any further liability concerning said contract.

*The affiant further states that there are no unpaid bills for labor, materials, supplies, or equipment used
in the execution and completion of said project, that no lien for any such labor, material, supplies, or expendable equipment has been filed according to law, (or if any such lien has been filed, it has now
been released); and there is no such claim, actual or alleged, known to this affiant.
The affiant further states that said company has no claim for any delay or damage whatsoever in
connection with said contract.
The affiant understands that nothing embraced herein shall be construed to release the contractor from
liability for the payment of any claims incurred for labor, materials supplies, or equipment used of
furnished for the use in the performance of the aforesaid contract, or from liability for damages, if any,
resulting from the wrongful or negligent acts of the contractor in the performance of the aforesaid
contract; and the contractor agrees to hold the Commonwealth of Kentucky and its agents and officials
harmless from any and all claims of any nature whatsoever.
Witness my hand, this the	day of
(Month)
(Year)
By
(Signature of Authorized Agent)
State of Kentucky )
)	Subscribed and sworn to before me by	on
County of	)	The	day of	,
(Month)
(Year)
(Notary Public)
My Commission Expires:

B-210-13

Department of Facilities Mgmt.

2012-11-02

Dad

Commonwealth of Kentucky