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f£-davit of Claim The Hartford <br />Commercial Surety Hartford Plazz T-4 <br />Hartford, CT 06105 <br />State of ) <br />ss. <br />County of ) <br />Being first duly sworn on oath I, <br />Marne of Atnensl <br />in my capacity as the <br />[Povtion in Firtn] <br />[Name of Claimant] [Corporauoq Permenhip, Limised Liability Company, Sole Propriemg Individuell <br />on behalf of said firm state as follows: <br />[Address] <br />located at <br />1) That ,hereinafter called Principal, is now and has been justly and truly indebted ro Claimant in <br />[Name of Principal] <br />the sum of $ <br />[Amwm of Clvm] <br />2) The facts and circumstances giving rise to this claim are as follows: <br />(Attach additional pages, if necessary). Attached hereto and incorporated herein are documents not previously provided which fully <br />support the. Claimants entitlement to the amount of the claim set forth herein. <br />3) There are no setoffs, counterclaims, claims or other credits due said Principal against said claim and Claimant is not indebted to Principal on <br />this or any other account, except .Claimant does no[ hold any note, collateral or <br />securiTy of any kind whatsoever forsaid claim and confirms that said claim is not encumbered nor has it been assigned. <br />4) This Affidavit and the supporting documentation is famished to the surety in support of the claim for the purpose of inducing <br />[None of Surety] <br />as surety for Principal to pay said claim. <br />5) Affiant has full knowledge of the statements contained herein and the basis therefore. Affian[ is dulyauthorized by Claimant [o <br />make said statements, present said claim and bind the claimant to the statements contained herein. <br />The famishing of this form by the surety and the acceptance and/or retention thereof does not constitute an admission of liabiity or a waiver of <br />any of the terms or conditions of the surety's bond, or any of the defenses the surety has or may have. The surety reserves [he right to request <br />additional documents or support for the claim. <br />Sworn and Subscribed to this day of <br />[Name of Claimant] <br />Tax tD No./Soc. Sec. <br />THIS AFFIDAVIT MUST BE EXECUTED BEFORE A NOTARY PUBLIC <br />Claim No.: 56a s zea33 Page 1 of 3 <br />