Request for Bond from Public Agency

Affidavit & Request for Bond

O.C.G.A. 13-10-64

Return To:





Party Providing Work

Name and Address of Party who provided the Services to the Project, and who is delivering this notice.




Public Authority

Name and Address of Public Authority in charge of the Project.




Description of labor and/or materials provided to the Property (Services):




Description of Project where Services were furnished (Project):




BEFORE ME, undersigned authority, personally came and appeared _________________________, who did declare under oath the following:

  1. That he/she is an authorized and disclosed agent of the above - identified Party Providing Work. A s the authorized and disclosed agent of the Party Providing Work, he/she has been provided with the facts related to this Affidavit and Request for Bond, and to the best of his/her information, knowledge and belief, the facts set forth herein are true and correct. He/she is competent and authorized to make this Affidavit.
  2. That the Party Providing Work has provided the above - identified Services to the above - described Project, and payment for the work provided has not been made.

Notice is hereby provided t o the Public Authority to furnish to the Party Providing Work a certified copy of the payment bond and the contract for the Project, as per O.C.G.A. § 13 - 10 - 64. These materials should be sent to ____________________________________ ____________________.



Subscribed and sworn to before me, on the ____ day of________________, 20____.

Notary Public

Signed this ____ day of _________________, 20____.

Agent for Party Providing Work

Signed by:


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