Commonwealth of Virginia s10

COMMONWEALTH OF VIRGINIA DEPARTMENT OF MINES, MINERALS AND ENERGY DIVISION OF MINED LAND RECLAMATION P. O. DRAWER 900; BIG STONE GAP, VA 24219 TELEPHONE: (276) 523-8100

AFFIDAVIT OF PAYMENT OF CLAIMS AND CERTIFICATION OF MATERIALS

By: Contract No. Contractor

Address:

This day ______personally appeared before me, ______, a Notary Public in and for the City (County) of ______, ______and, being by me first duly sworn/affirmed, states that all materials meet or exceed the specifications of the Contract and that all subcontractors and suppliers of labor and materials have been paid all sums due them for work performed or materials furnished in the performance of the Contract between the Commonwealth of Virginia, Department of Mines, Minerals and Energy, Division of Mined Land Reclamation, Owner, and ______, Contractor, dated ______, 20__, for the construction of ______project or arrangements have been made by the Contractor satisfactory to such subcontractors and suppliers with respect of payment of such sums as may be due them by the Contractor.

By: ______Signature ______Typed Name & Title of Person Signing

Subscribed and sworn/affirmed to before me this _____day of ______, 20 __. My commission expires on the ______day of ______, 20 __.

Notary Registration No. ______Notary Public1 (affix seal)

1 Pursuant to §47.1-15(3) of the Code of Virginia, as amended, the notarial certificate wording must be contained on the same page as the signature being notarized.

DMLR-AML-314 Rev. 03/09