Form 121

OWNER/GENERAL CONTRACTOR SETTLEMENT AFFIDAVIT

Commonwealth of Virginia

County/City ____________________

On this day before me personally appeared the undersigned, who makes this Affidavit individually and in the capacity indicated below, to me personally known, who being duly sworn on oath states and certifies that:

The undersigned is/are the owner(s) of the property hereafter described and has caused there to be certain construction or repair of improvements located on said property and that said construction or repair was made under the supervision of the undersigned and that all persons, firms or other entities who have furnished services, labor or materials used in the construction or repair of such improvements have been paid in full, unless otherwise indicated on Exhibit A of this Affidavit;

There are no mechanics’ or materialmen’s liens against said property and no liens outstanding which would entitle the holder thereof to claim a lien against the property, except those claims on Exhibit A; and

The construction or repair of improvements have been fully completed.

The undersigned states and certifies that the proceeds form the sale of said property are sufficient to pay all bills, claims, etc. of persons, firms and other entities appearing on Exhibit “A” hereof and that payment shall be made in full of all such bills, claims, etc. The undersigned further states and certifies that a portion of the proceeds from the sale of said property, sufficient to pay all bills, claims, etc. of persons, firms or other entities appearing on Exhibit “A”, shall be retained and held in trust on behalf of the purchaser of the property, purchaser’s lender and OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY until applied to those claims of persons, firms or other entities who have not, at the time of settlement, been paid in full. Said trust shall be extinguished upon satisfaction, in full, of all bills and claims.

That this Affidavit is provided at the time of settlement on the sale of the property and provided to the purchaser pursuant to Virginia Code Section 43-13.2 and is made for the purpose of inducing the purchase of the property, the making of the loan on said property and OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY to issue its policies insuring the title to said property without exception to the claims of mechanics, materialmen and laborers, and the undersigned does hereby indemnify and hold OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY of and from any and all liability, loss, cost, damage and expense if every kind, including attorney’s fees, which said OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY shall or may suffer or incur or become liable for under its said policies directly or indirectly due to or because of (1) OLD REPUBLIC NATIONAL TITLE INSURANCE COMPANY relying on the assurance and statements made herein and (2) claims of all persons, firms or other entities performing labor or furnishing services or materials in connection with the construction or repair of improvements on said property with whom the undersigned is or is not in privity of contract.

The undersigned acknowledge and certify that this Affidavit has been read and understood and the undersigned fully understand and acknowledge that the willful material misrepresentation with respect to such statements contained herein which cause monetary loss to a financial institution, title company, contractor, subcontractor, supplier, owner, mechanics’ lien agent or any other person or institution shall be punishable as a Class 5 felony.

The real estate and improvements referred to herein are briefly described as:

Signed and certified to this _____ day of ____________________, 20____.

	Owner/General Contractor
	_______________________________________________

	By: _____________________________________________ (Seal)
	Title: ___________________________________________
	____________________________________________
	Please Print Name
Executed, subscribed and sworn to before me on the day, month and year above written.
	______________________________________
	Notary Public
My commission expires: ________________________
I/we personally affirm and guaranty that all information and statements made herein are true and correct.
	_________________________________________________ (Seal) _________________________________________________ (Seal)
Executed, subscribed and sworn to before me on the day, month and year above written.
	______________________________________
	Notary Public
My commission expires: ________________________

___________________________________________________________________________________________________________

EXHIBIT “A”

Claims and Payables

(Persons, firms or other entities performing labor or furnishing materials)

Name	Address	Telephone #	Amount Payable or Claimed
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______
______________________	___________________________	___________	_______

Settlement Affidavit