Bond Claim/Verified Claim Form

Prepared By and Return To:

 

 

 

Verified Claim and Surety Bond Claim CRS 38-26-107

The  Claimant: (Name & Address)

 

 

 

 

The  Property Owner / Public Entity: (Name & Address)

 

 

 

 

The  Prime Contractor: (Name & Address)

 

 

 

 

The  Surety: (Name & Address)

 

 

 

 

 

Bond No.

 

Services Furnished At the Instance of: (Name & Address – if same as Prime, note “Same as Prime”)

 

 

 

 

(Hereinafter “Hired-By Contractor” )

The  Project:

Address & Description:

 

 

 

 

 

Name of Project:

 

 

County of

 

State of Colorado

This Verified Claim Sent via Certified Mail with Return Receipt Requested:

 

To Public Entity with No.

 

To Surety with No:

 

To Public Entity with No.

 

To Prime Contractor with No:

 

THIS DOCUMENT SHALL BE ACCEPTED BY YOU AS NOTICE, pursuant to Colorado Revised Statutes, Section 38-26-107, that the Claimant furnished labor, materials, services, supplies, equipment, tools, and/or other construction services (hereinafter “Services”) used in or consumed in the Project.

The Claimant verifies and certifies that $______________________, together with interest thereon, remains due and unpaid and owing to the Claimant, on account of the Claimant’s furnishing of the Services. These Services were furnished at the request of the Hired-By Contractor.

Claimant pleads the benefit of CRS 38-26-107 et seq. by the sending of this Notice. Further, and specifically, the Claimant makes claim against the above-referenced bond of the Surety for the above-stated amount, plus interest.

SIGNATURE OF CLAIMANT, AND VERIFICATION

Executed on the ____ day of __________________, 20____

I, _________________________, being of lawful age and being first duly sworn upon oath, do say I am a disclosed agent of the Claimant named herein, appointed for the express purpose of signing this verified claim; that I have read the verified claim, and know the contents thereof; that to the best of my knowledge, information and belief, the same is true and correct, and made on behalf of the Claimant. I also swear and verify that I sent this Verified Notice via U.S. certified or registered mail, with return receipt requested, using the certified or registered mail numbers identified within the Verified Claim, to the parties identified in association with those mail parcel numbers. Postage was prepaid. These Verified Claims were sent on the same day as this document was executed, which is above-identified.

Agent of Claimant

Signed by

STATE OF

COUNTY OF

Sworn to and subscribed before me, undersigned Notary Public, on the date above identified, the stated and disclosed agent of the Claimant.

Notary Public

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