FLOOD10379 ‎(2)‎

• County: Adams
• County: Arapahoe
• County: Denver
• Stream Name: South Platte River
• Title: UDFCD South Platte River Program 2003 Routine Maintenance Contract Documents
• Date: 1/1/2003
• Prepared For: CWCB
• Prepared By: Urban Drainage and Flood Control District
• Floodplain - Doc Type: Floodplain Report/Masterplan

.

Revised 1/03

611
CONTRACTOR STATEMENT CONCERNING CLAIMS
. 2003 SOUTH PLATTE RIVER ROUTINE MAINTENANCE
(Project No. 03-01.01)

The CONTRACTOR under that certain AGREEMENT dated , 20_ by and
between OWNER and said CONTRACTOR for construction of the above-referenced PROJECT states,
. represents and warrants that CONTRACTOR has fully completed all construction included in the
CONTRACT and all authorized CHANGE ORDERS thereto; and has fully paid for all materials,
equipment, supervision, labor, services, taxes, use of equipment, and all other costs and expenses of the
construction; and that there are no disputes, claims or liens against the OWNER, the CONTRACTOR,
or any SUBCONTRACTOR of CONTRACTOR; and that the CONTRACTOR will have no claims
against the OWNER of any kind whatsoever arising from or growing out of the CONTRACT, except as
. follows:

Claimant

Description of Claim

Amount

.

CONTRACTOR:

Company Name (print)

.

By:

(signature)

Name:

(print)

Title:

.

STATE OF COLORADO)
) SS.
COUNTY OF )

.

, being first duly sworn, on oath deposes and states: that he/she is the
of the aforesaid CONTRACTOR, that he/she makes this affidavit for and
on its behalf and is authorized so to do, that he/she has read the foregoing Statement Concerning Claims
and has personal knowledge of the facts contained therein and acknowledges said Statement Concerning
Claims to be the free and voluntary act and deed of the CONTRACTOR for the purpose of obtaining
final payment under the CONTRACT described herein, that he/she was authorized to execute the same
for and on behalf of the CONTRACTOR and that said Statement Concerning Claims is true and correct.

.

Subscribed and sworn before me this _ day of

,20_

[SEAL]

.

NOTARY PUBLIC
State of
Address:

My Commission Expires:

.

spr\RoutContract

Section 600-(9)