OWNER'S AFFIDAVIT AS TO LIENS AND POSSESSION

Title Insurance File No. _______________________________

STATE OF WISCONSIN	)

) SS

COUNTY OF _______________________	)

The undersigned, (Affiant), being first duly sworn on oath deposes and says:

The Affiant is the owner of certain premises located at: ___________________________________________, Wisconsin.

1.	(a) That there have been no improvements constructed or repairs of existing improvements on said property within the last six months, and that no work has been done and no labor or materials have been furnished to said premises; (or)

(b) That all improvements upon said property, including the construction or repair thereof made within the last six months have been made under the supervision of _____________________________________ as contractor employed by the Affiant to make said improvements and that same were accepted as fully completed on or about the ______ day of _____________________________, 20____;

Note:	Fill in only applicable paragraphs above and strike out others. If work has been done by a contractor, the contractor must provide lien waivers for the same to this affidavit.

2.	That all bills or obligations incurred in connection with said improvements if any, including the construction or repair thereof, have been paid in full and that there are no claims for labor, services or material furnished in connection with said improvements which remain unpaid, except: (if any unpaid, name claimants and amount due each). __________________________________________________________________________________________

3.	That there is no person in actual possession or having a right to possession of said property or any part thereof, other than said owner(s), except: (set out names and interest claimed; if none, word "none" must be added) ___________________________________________________________________________________________

4.	That as of the date hereof there are no pending actions or proceedings for or relating to any bankruptcy, receivership, foreclosure, divorce, probate, or any other actions or proceedings affecting the conveyance of said property; and that there are no unsatisfied mortgages, security agreements, indentures, judgments, construction liens, state or federal tax liens, land contracts, leases, restrictive covenants, easements, rights-of-way, reverters, reversionary rights, interests or estates in minerals, trusts, assessments, general or special taxes or other liens, agreements or adverse rights affecting said property except those specifically referred to in the above mentioned commitment issued for the subject property, except: (list any exceptions; if none write "none")._______________________________________________

5.	That there are no unpaid bills for, conditional bills of sale, financing statements or other liens affecting any fixtures used in connection with the improvements upon said property, except: ________________________________________

6.	That the improvements (building, fence, driveway or other structure) occupied, used or claimed by the Affiant herein are wholly within the boundary lines of said property and that no buildings, fences, driveways or other structures of any adjoining owner encroach upon any part of said property. (List any exceptions; if none write "none". If there is any uncertainty about the existence or location of boundaries or encroachments by reason that no current survey has been prepared, any potential or questionable encroachments must be identified and described in the space provided).

Boundary or Encroachment Matters:	a.___________________________________________________________

b.___________________________________________________________

7.	That the Affiant hereby expressly agrees to indemnify and save harmless Heritage Title Services, Inc., and its underwriters, from any and all loss, liability, claim or action arising from, or omissions relating to the items set forth above.

______________________________________________________

Affiant

Subscribed and sworn to before me this ______ day of __________________________, 20_____.

___________________________________________________

Notary Public

My commission expires ______________________________