To: xxxxxxx Bond Co.

xxxx Name
Tel: xxxxxxxxx Fax: xxxxxxx
Re: Bond #xxxxxxxxxxx

STATEMENT OF CLAIM INFORMATION FOR CONTRACT PAYMENT BOND

Datexxxx
Attached please find contract and invoice summary statement between Paving Net Contractor & Supply and
Primexxxx

Indentifying Information
Bond Number: xxxxxx Principle: Primexxxx
Project Name: xxxxxxxx
Project Address: xxxxxxxxxx

Claimant Information
Name: Paving Net Contractor & Supply
Address: 11 S. Termino Ave, Suite 214, Long Beach, CA 90803
Tel: (800) 599-6996 Fax: (562) 439-1398 Cell: (714) 642-0548
Email: info@pavingnet.com Contractor’s License Number: 302363
Website: http://www.PavingNet.com
Contact: Henry W Sprague III, certified DVBE owner

Form of business entity: State Licensed Contractor, Certified Disabled Veteran Business Enterprise,
Certified Small Business Enterprise, Sole Proprietor.

Relationship to Principal: DVBE/DBE/SBE Subcontractor Consultant and Material Supplier.

Debtor Information (Person or company who owes claimant)

Name: Primexxxxxxx
Address: xxxxxxx
Tel: (xxx) xxxxxx Contact Person: xxxxx

Debtor’s Role on project: General Contractor__X__ Subcontractor____ Other____

Contract or Agreement Information

Type: Contract_X__ Subcontract___ Purchase Order___ Open Account___ Other___
Was your agreement in writing? Yes Date of Agreement xxxxxx See attached contracts
Was your agreement: Fixed Price__X___
1 Original agreed price: $_000000.00
2 Approved / undisputed increases: $_____
3 Pending, unapproved or disputed increases: $_____
4 Approved / undisputed deductions: $_____
5 Disputed deductions: $_____
6 Actual amount paid on account to date: $_____
7 Retention withheld: $_____
Claim Details
Amount of Claim $_000000.00
What labor, material, etc., did you provide?
$0000 labor, $00000 Tree’s, $000000 tax
 _________________________________________________________________________________________
Percentage of your obligation which you have performed? 100%
Date when first provided contracted services: Datexxxxx
Date when last supplied contracted services: Datexxxx See attached
Amount you owe to others on the project:
Creditor Amount Owed
____________________________________ $__________________________________________
____________________________________ $__________________________________________
____________________________________ $__________________________________________
Are you aware of any setoffs, counterclaims, back charges, or other credits available to or asserted by the
debtor against you on this project? Yes ____ No _X___
If so, why and for how much? _______________________________________________________________

1. Was a 20-Day Preliminary Notice mailed by claimant via certified mail, return receipt requested?
Yes If so when did you file? Datexxxx
With whom? Awarding Dept xxxx
2. Have you filed an Intent to Lien on this project?
Yes faxed Intent to Lien on Datexxxx
3. Have you filed a Stop Notice on this project?
Yes If so when did you file? Datexxxxx

Have you filed any lawsuits in connection with this project? Yes ____ No.__X___
If so, what court?_________________________________ Case Number:_________________________
When filed:______________________________ Defendant(s) named: ______________________________
What state?______________________________ What county?____________________________________
Attorney name, address and phone:____________________________________________________________
________________________________________________________________________________________
Have you obtained any judgments in connection with your claim? Yes _____ No __X___
If so, against whom? _______________________________________________________________________
When?_______________________________ For how much?
$____________________________________
Do you hold any note or security for your claimed debt? Yes_____ No __X___
If so, what do you hold and for what amount? ___________________________________________________
Are you indebted to the debtor on this or any other account? Yes _____ No __X___
If so, why and for how much? ________________________________________________________________

THE FOREGOING information is furnished to the surety in support of the claim described above. It is understood that
surety’s furnishing, acceptance and/or retention of this form does not constitute an admission of liability nor a
modification or waiver of: 1) any bond term; 2) any right or defense available to the surety (all of which are expressly
reserved); nor 3) any term of the surety’s bond.

Claimant agrees that all guarantees and warrantees required under the terms of its agreement pertaining to work, labor and
materials, which it furnished, shall remain in full force and effect in accordance with their terms.

I certify, under penalty of perjury, that all information contained in this form and all documents enclosed with it are
accurate and complete to the best of my knowledge and belief. I further certify that I am authorized to sign this Proof of
Claim form on behalf of the Claimant.

Date: _______________ ____________________cell (714) 714-0548

Signature of claimant or authorized representative

_____________________________________________
Name and title or position