Fill and Sign the Conditional Release Progress Payment Form

CONDITIONAL WAIVER AND RELEASE UPON PROGRESS PAYMENT- INDIVIDUAL Property Name: __________________________________ Property Location: _______________________________________________________ Undersigned's Customer: __________________________________ Invoice/Payment Application Number: _____________________________ Payment Amount: ________________________ Upon receipt by the undersigned of a check in the above-referenced Payment Amount payable to the undersigned, and when the check has been properly endorsed and has been paid by the bank on which it is drawn, this document becomes effective to release and the undersigned shall be deemed to waive any notice of lien, any private bond right, any claim for payment and any rights under any similar ordinance, rule or statute related to payment rights that the undersigned has on the above-described Property to the following extent: ________________________________________________________________________ _______________________________________________________________________ . This release covers a progress payment for the work, materials or equipment furnished by the undersigned to the Property or to the Undersigned's Customer which are the subject of the Invoice or Payment Application, but only to the extent of the Payment Amount or such portion of the Payment Amount as the undersigned is actually paid, and does not cover any retention withheld, any items, modifications or changes pending approval, disputed items and claims, or items furnished that are not paid. Before any recipient of this document relies on it, he or she should verify evidence of payment to the undersigned. The undersigned warrants that he or she either has already paid or will use the money he or she receives from this progress payment promptly to pay in full all his or her laborers, subcontractors, materialmen and suppliers for all work, materials or equipment that are the subject of this waiver and release. This the _____ day of _______________ , 20 ______ . ______________________________ Signature _____ _________________________ Type or Print Name Conditional Waiver and Release upon Progress Payment Page 1 of 2 State of Nevada County of _______________ This instrument was acknowledged before me on ____________ by __________________________________ . _________________________ (Signature of notarial officer) (Seal, if any) _________________________ (Title and rank (optional)) (My commission expires (optional): ___________ ) Certificate of Delivery I, __________________________________ , hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ by: ( ) Personal Service ( ) Mailing a true and correct copy of same by certified U.S. mail, postage prepaid, return receipt requested to _______________________________ . So certified this the _____ day of _____________ , 20 ______ . ________________________ Signature Conditional Waiver and Release upon Progress Payment Page 2 of 2