Fill and Sign the 497432257 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ___________________ Address: ____________________ City: ___________________ State: _____ Zip: __________ Phone: _________________ Fax: __________________ CONDITIONAL WAIVER AND RELEASE OF LIEN UPON FINAL PAYMENT On this _____ day of ________________ , 20 ______ , the undersigned lienor, whose address is ______________________________________________________________________ , in consideration of the final payment in the amount of $ _________________ , hereby waives and releases his or her lien and right to claim a lien for labor, services or materials furnished through _________________________________ , 20 _____ , to _________________________ (customer) on the job of _________________________ (owner of property) to property located at and described as: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . This Conditional Waiver and Release of Lien Upon Final Payment is conditioned upon the undersigned receiving collected funds in the amount of $ ___________________ for the work described herein. Should these funds not be received within _____ days of the date hereof, this Conditional Waiver and Release of Lien is void. This waiver and release covers the final payment to the undersigned for all labor, services, equipment, or material furnished on the job. Before any recipient of this document relies on it, the party should verify evidence of payment to the undersigned. ______________________________ Signature of Lien Holder _____ _________________________ Type or Print Name Conditional Waiver and Release of Lien Upon Final Payment Page 1 of 2 STATE OF WYOMING COUNTY OF __________________ This instrument was acknowledged before me on the ______ day of ______________ , 20 ______ , by __________________________________ (name(s) of person(s)). ___________________________________ (Seal, if any) (Signature of notarial officer) ___________________________________ Title (and Rank) My Commission Expires: __________________ Conditional Waiver and Release of Lien Upon Final Payment Page 2 of 2