Fill and Sign the Family Health America L Empower Chiro Form

Conditional Waiver and Release of Lien Page 1 of 2Prepared by, recording requested by and return to:Name: _____________________Company: _____________________Address:_______________________ City: ____________________State: _____Zip: _________Phone: _________________Fax: ___________________UPI Number: ________________----------------------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: ________________________________________________________________________________________________________________________________________________ ___________________________________________________________________ (address should include municipality, ward (if in the city of Pittsburgh), county and state) (legal description should include a metes and bounds description; a lot, block, subdivision; the book and page and/or instrument number of a recorded deed where the legal can be found; or a parcel in a partition). 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 ______________________________ Conditional Waiver and Release of Lien Page 2 of 2 Type or Print Name COMMONWEALTH OF PENNSYLVANIACOUNTY OF _________________ On this, the ___ day of __________, 20____, before me a notary public, the undersigned officer, personally appeared________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. In witness hereof, I hereunto set my hand and official seal. ___________________________ Notary Public ___________________________ Printed Name (Stamp or Seal)________________My Commission Expires: _____________________