Fill and Sign the For the Work Described Herein Form

Conditional Waiver and Release of Lien Upon Progress Payment Page 1 of 2 Prepared by, recording requested by and return to: Name: _____________________ Company: _____________________ Address:_______________________ City: ____________________ State: _____ Zip: _________ Phone: _________________ Fax: _________________ Reference # ___________________ ----------------------Above this Line for Official Use Only--------------------- CONDITIONAL WAIVER AND RELEASE OF LIEN UPON PROGRESS PAYMENT On this _____ day of ________________, 20______, the undersigned lienor, whose address is ______________________________________________________________________, in consideration of the sum of $ ___________________, does hereby waive and release 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 the property located at and described as: ___________________________________________________________________________________________________________________________________________________________________________________________________________________. This Conditional Waiver and Release of Lien Upon Progress 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 does not cover any retention or labor, services, or materials furnished after the date specified. ______________________________ Signature of Lien Holder______________________________ Type or Print Name Conditional Waiver and Release of Lien Upon Progress Payment Page 2 of 2 STATE OF WASHINGTON COUNTY OF ___________________ On this day personally appeared before me _______________________________, to me known to be the individual(s) described in and who executed the within and foregoing instrument, and acknowledged that he/she/they signed the same as his/her/their free and voluntary act and deed, for the uses and purposes therein mentioned. Given under my hand and seal of office this _____ day of _____________, 20_________. ______________________________ Notary Public residing at _________ Printed Name: _________________ My Commission Expires: ___________________