Fill and Sign the Georgia Waiver Payment Form

After Recording Return to:                         INTERIM WAIVER AND RELEASE UPON PAYMENT (INDIVIDUAL) STATE OF GEORGIA COUNTY OF __________________ THE UNDERSIGNED MECHANIC AND/OR MATERIALMAN HAS BEEN EMPLOYED BY __________________________________ (NAME OF CONTRACTOR) TO FURNISH _____________________________________ (DESCRIBE MATERIALS AND/OR LABOR) FOR THE CONSTRUCTION OF IMPROVEMENTS KNOWN AS ___________________________________ (TITLE OF THE PROJECT OR BUILDING) WHICH IS LOCATED IN THE CITY OF _____________________ , COUNTY OF _____________________ , AND IS OWNED BY ________________________ (NAME OF OWNER) AND MORE PARTICULARLY DESCRIBED AS FOLLOWS:       [INSERT FULL LEGAL DESCRIPTION ABOVE. DESCRIBE THE PROPERTY UPON WHICH THE IMPROVEMENTS WERE MADE BY USING EITHER A METES AND BOUNDS DESCRIPTION, THE LAND LOT DISTRICT, BLOCK AND LOT NUMBER, OR STREET ADDRESS OF THE PROJECT.] UPON THE RECEIPT OF THE SUM OF $ __________________ , THE MECHANIC AND/OR MATERIALMAN WAIVES AND RELEASES ANY AND ALL LIENS OR CLAIMS OF LIENS IT HAS UPON THE FOREGOING DESCRIBED Interim Waiver and Release Upon Payment Page 1 of 2 PROPERTY OR ANY RIGHTS AGAINST ANY LABOR AND/OR MATERIAL BOND THROUGH THE DATE OF _____________________ (DATE) AND EXCEPTING THOSE RIGHTS AND LIENS THAT THE MECHANIC OR MATERIALMAN MIGHT HAVE IN ANY RETAINED AMOUNTS, ON ACCOUNT OF LABOR OR MATERIALS, OR BOTH, FURNISHED BY THE UNDERSIGNED TO OR ON ACCOUNT OF SAID CONTRACTOR FOR SAID BUILDING OR PREMISES. GIVEN UNDER HAND AND SEAL THIS _____ DAY OF ________________ , ______ . (Seal)       Type or Print Name (Witness)       Type or Print Name       Street Address       City, State and Zip NOTICE: WHEN YOU EXECUTE AND SUBMIT THIS DOCUMENT, YOU SHALL BE CONCLUSIVELY DEEMED TO HAVE BEEN PAID IN FULL THE AMOUNT STATED ABOVE, EVEN IF YOU HAVE NOT ACTUALLY RECEIVED SUCH PAYMENT, 60 DAYS AFTER THE DATE STATED ABOVE UNLESS YOU FILE EITHER AN AFFIDAVIT OF NONPAYMENT OR A CLAIM OF LIEN PRIOR TO THE EXPIRATION OF SUCH 60 DAY PERIOD. THE FAILURE TO INCLUDE THIS NOTICE LANGUAGE ON THE FACE OF THE FORM SHALL RENDER THE FORM UNENFORCEABLE AND INVALID AS A WAIVER AND RELEASE UNDER O.C.G.A. SECTION 44-14-366. Reference: 44 - 14 - 366(c). Interim Waiver and Release Upon Payment Page 2 of 2