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hilt� DANE <br /> •DCTC111 COUNTY <br /> -'"•("if•ri' TITLE COMPANY <br /> DANE COUNTY TITLE COMPANY <br /> 901 S WHITNEY WAY <br /> MADISON,WI 53711 <br /> Phone:608-271-2800 Fax:608-271-8836 <br /> www.danecountytitle.com <br /> CHICAGO TITLE INSURANCE COMPANY <br /> Construction Work and Tenants Affidavit <br /> 1. I am the Owner of the property(the Property)described in commitment number C-15077625 issued by <br /> DANE COUNTY TITLE COMPANY,an agent for CHICAGO 1 II'LE INSURANCE COMPANY. <br /> 2 Construction work.(check one box) <br /> ERepair or construction work has not been done on the Property in the past six months. <br /> ['Repair or construction work has been done on the Property in the past six months.The total dollar amount of the <br /> work is approximately$ .All of the people who supplied labor or material are listed <br /> below.All lien waivers I collected from these people are stapled to this affidavit. <br /> Type of work Contractor Name Dollar amount of work Date of work <br /> 3. Tenants.The following tenants and renters occupy the Property:(check one box) <br /> here are no tenants. <br /> ❑There are tenants,but all have left the Property or will leave as of closing. <br /> ❑One or more tenants will stay after this transaction is closed.Their name(s)are: <br /> 4. Special Assessments.(check one box) <br /> ❑ sere are no unpaid special assessments,charges for water or sewer hookup or service,or other tax liens on the <br /> 1,4perty. <br /> ❑There are unpaid special assessments, charges for water or sewer hookup or service, or other tax liens on the <br /> property.They are for <br /> 5. Association dues and assessments.(check one box) <br /> [J.Tliere are no association dues owed to my condominium or homeowner's association. <br /> ❑There are condominium or homeowner's association dues owing in the amount of$ <br /> I give this affidavit to persuade CHICAGO 111 LE INSURANCE COMPANY to issue its policy or policies of title <br /> insurance.I agree to indemnify CHICAGO TITLE INSURANCE COMPANY against loss caused by inaccuracies or <br /> omissions in the above information of which I am aware. <br /> Dated this 20th dayery,2015 <br /> Owner Sworn: S bscnb d before •is •I. day of May,2015 <br /> Notary Pub' State of ' co w.0 <br /> /��.—/� ..✓ My Commission •rres: <br /> ARBARA A.ZIE c L' <br /> \\p�uw i m,nu�q <br /> �?OD A R'r/� <br /> AUg1. <br /> .sT,�TE OF <br />