Fill and Sign the Claim Payment Bond Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ___________________ Address: _____________________ City: __________________________ State: _____ Zip: _____________ Phone: _____________________ Fax: _______________________ WAIVER OF RIGHT TO CLAIM AGAINST THE PAYMENT BOND (FINAL PAYMENT) - INDIVIDUAL The undersigned lienor, in consideration of the final payment in the amount of $ __________________ , hereby waives his or her right to claim against the payment bond for labor, services, or materials furnished to ___________________________________ (customer) on the job of __________________________________ (owner of property) , for improvements to the following described project: ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ . DATED on _____ day ___________________ , 20 _____ . Lienor's Name _________________________ Address ______________________________ By _________________________ Printed Name _____ _____________________ Waiver of Right to Claim Page 1 of 2 STATE OF ___________ COUNTY OF _____________ Sworn to (or affirmed) and subscribed before me this _____ day of _________________, 20______ by _________________________ (name of person making statement) who is personally known to me or produced _________________________ as identification, and who did take an oath. ____________________________ NOTARY PUBLIC Printed Name of Notary _________________________ Commission Expires _________________________ Waiver of Right to Claim Page 2 of 2