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<br />Revised 1/03 <br /> <br />.1 <br /> <br />612 <br />WITHDRAW AL OF STATEMENT OF CLAIM <br />2003 SOUTH PLATTE RIVER ROUTINE MAINTENANCE <br />(Project No. 03-01.01) <br /> <br />. <br /> <br />(Claimant) <br /> <br />TO: Urban Drainage and Flood Control District <br />2480 West 26th Avenue, Suite 156B <br />Denver, Colorado 80211 <br /> <br />. <br /> <br />BOND COMPANY <br /> <br />CONTRACTOR: <br /> <br />\ <br /> <br />Company Name (Print) <br />Address <br /> <br />. <br /> <br />Company Name (Print) <br />Address <br /> <br />and to whom it may concern: <br /> <br />. <br /> <br />YOU ARE HEREBY NOTIFIED that the Statement of Claim dated , 20 in the <br />amount of $ and previously filed with the Urban Drainage and Flood Control District by <br />in regard to the above-referenced PROJECT, is hereby withdrawn <br />WITH PREJUDICE effective immediately. <br />Dated at , Colorado this day of , 20_. . <br /> <br />Claimant: <br /> <br />(signature) <br /> <br />Name: <br /> <br />(print) <br /> <br />. <br /> <br />Title: <br /> <br />STATE OF COLORADO) <br />) SS. <br />COUNTY OF ) <br /> <br />. <br /> <br />, being first duly sworn on oath, deposes and states: that he/she is <br />the of the Corporation, Partnership, or Individual named <br />as claimant in the foregoing Withdrawal of Statement of Claim, and the person who executed the said <br />Withdrawal of Statement of Claim on behalf of said Corporation, Partnership or Individual, and that all <br />of the statements contained herein are true. <br />Subscribed and sworn before me this _ day of , 20_ <br /> <br />. <br /> <br />[SEAL] <br /> <br />NOT ARY PUBLIC <br />State of <br />Address: <br /> <br />. <br /> <br />My Commission Expires: <br /> <br />cc: CONTRACTOR <br />Bond Company <br /> <br />. <br /> <br />spr\RoutContract <br /> <br />Section 600-(10) <br />