Chapter 12 - EXHIBIT 12F • VERIFIED STATEMENT OF CLAIM (COLORADO PUBLIC WORKS ACT)

• Jurisdiction: Colorado

EXHIBIT 12F • VERIFIED STATEMENT OF CLAIM (COLORADO PUBLIC WORKS ACT)

VERIFIED STATEMENT OF CLAIM

TO: [PUBLIC CONTRACTING BODY]

STATE OF COLORADO

COUNTY OF__________

SS.

The undersigned [CLAIMANT] has furnished labor and/or materials itemized on attachment A hereto to [PRIME CONTRACTOR] for use on [PUBLIC CONTRACTING BODY'S] prime contract with the [PRIME CONTRACTOR] located at or near [LOCATION OF PROJECT] known as [PROJECT NUMBER AND FULL DESCRIPTION]. The said [PRIME CONTRACTOR] has not paid for the said labor and/or materials rendered and there is due and payable to the undersigned the sum of [$AMOUNT]. The...