Fill and Sign the Before Any Recipient of This Form

Prepared by, recording requested by and return to: Name: ___________________ Company: ___________________ Address: ____________________ City: ___________________ State: _____ Zip: __________ Phone: _________________ Fax: __________________ ----------------------Above this Line for Official Use Only--------------------- 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 This instrument was prepared by _______________. STATE OF WEST VIRGINIA COUNTY OF ________________This instrument was acknowledged before me on ________________ (date) by _________________________________ (name or names of person or persons acknowledging). _________________________ Notary Public Printed Name: ____________________ My Commission Expires: _______________