We, the undersigned, being respectively the Seller and Contractor, do hereby certify that the Contractor has performed labor or delivered materials or both to (address of property) .........., in connection with a contract to .........., and that as of this date the value of the labor performed and materials delivered is $.......
We do further certify that in connection with such contract there remains labor to be performed, and materials to be delivered, of the value of $........
This Certificate is signed (insert date). ............ ..
.......... Seller Contractor
A person who executes and delivers a completion certificate with actual knowledge of a falsity contained therein shall be considered in violation of this Act and subject to the penalties contained herein.
815 ILCS 390/19