AFFIDAVIT OF NONPAYMENT UNDER
O.C.G.A. SECTION 44-14-366

STATE OF GEORGIA

COUNTY OF ________________

The undersigned mechanic and/or materialman has been employed by ____________________________ (name of contractor) to furnish (describe materials and/or labor) for the construction of improvements known as ____________________________ (title of the project or building) which is located in the City of ____________________, County of ____________________, and is owned by ____________________________ (name of owner) and more particularly described as follows:

[Legal Desc. Here]

(DESCRIBE THE PROPERTY UPON WHICH THE IMPROVEMENTS WERE MADE BY USING EITHER A METES AND BOUNDS DESCRIPTION, THE LAND LOT DISTRICT, BLOCK AND LOT NUMBER, OR STREET ADDRESS OF THE PROJECT.)

Pursuant to O.C.G.A. Section 44-14-366 the undersigned executed a lien waiver and release with respect to this property dated ________________, 19____. The amount set forth in said waiver and release ($____________) has not been paid, and the undersigned hereby gives notice of such nonpayment.

The above facts are sworn true and correct by the undersigned, this ________ day of ____________, 19____.

___________________________ (SEAL)
Claimant's Signature

Sworn to and executed

in the presence of:

______________________
Witness

______________________
Notary Public