ST0004-CN011230MODEL FORMS
/ "~ APPENDIX<A. 1
CONTRACTOR'S AFFIDAVIT OF F1NAL PAYMENT
THE STATE OF TEXAS )
OF /~- '/~/Z~_ff~t~//,~ ) KNOW ALL MEN BY THESE PRESENTS:
COUNTY
. )
BEFO~ ME, ,he unde.lgned authority, on this day pe--onafly appeared ~¢~~
("~ffia~t'), w~o ~er~eing ~ me duly sworn, deposes, and says that he b '~ h/l /~
~ f~~oor.tion, ~, ~) of ~f?~~ Co.my,
State of Tex~ (~he Con~a~or"), which said Co~tractor was aw~ded the ~ntrac~dated ~he day of
,20~/ forthe.nstructionof ~~ ~~ ~'~ at
~/ ~ ' (the ~o~k'), for a total~onsid~ratDn of
~,~ ~ / Dollars to be paid to the said Contractor (the "Contract~, and that Amdant has fun
power of authority to make this a~davit.
That ~ ~ ~ (the "~er') has app~ved the final estimate on said Wor~
and that the said C~nt~ctor ff~ fully satisfied and paid any and ~ claims that may be cove~d by Chapter 53
of the Texas P~pe~y Code and A~icle 5160 of the Revised Civil Statutes of the State of Texas, or any other
app~able statutes or cha~er p~visions, and that all just bills for labor ~d mate~als have b~n paid and
discha~ed by said Contractor insofar as they pe~ain to the work in question.
That in addit~n to a~ funds which may have been p~viously paid by the ~er, the Contractor
he.by accepts the amount o~ ~ ~ ~ ~ ~ Dolla~ ~ FULL AND F~AL PA~E~ under the
afo~mentioned Contract~ and he.by waives and ~leases any ~ght A~dant an~or the Contractor may have
to pu~ue claims of any natu~ against the Owner a~sing but of or in any manner ~nn~ed with the
pe~o~ance of the Work an~or the Contract, including but not I~ited to claims of third pa~ies that supplied
mate~al an~or labor for the Work for or though the Contra~or ("Subcontra~o~'), ~ well as cica for
delay, addit~n~ ~m~nsation or for ~ove~ of liquidated damages wh~h may have b~n ~thheld by the
~ner. The Contra~or shah defend, hold harlem and indemnify the ~ner f~m any such cin~s of such
Su~ntracto~. ~e Contractor fu~her ~leases the ~er f~m any claim or HabHity a~s~g f~m ~y act or
neg~t of the ~ner ~lated to or connoted with the ContracL ~is a~davit is given pursuit to the final
payment p~visions of the Contract, and shall not be deemed to alter or modify the te~s and p~visions of said
Contract.
QUANTUM CONTRACTING, INC.
~iZant) O' RJ. EvenS, Jr.
Vice President
(Printed Name)
SUBSCRIBED AND SWORN TO BEFORE ME, this the ~ day of/~-~C' EL A.D., 20 ~ ]
(Notary Public in and for the State of Texas)
(Printed Name of Notary)
My commission expires -~--/
January i998