Fill and Sign the Her Lien and Right to Claim a Lien for Labor Services or Materials Furnished through Form

Unconditional Waiver and Release of Lien Page 1 of 2 Prepared by, recording requested by and return to: Name: ___________________ Company: ___________________ Address: ____________________ City: ___________________ State: _____ Zip: __________ Phone: _________________ Fax: __________________ UPI Number: ________________ ----------------------Above this Line for Official Use Only--------------------- UNCONDITIONAL 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 $ __________________, 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: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________ (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 waiver and release does not cover any retention or labor, services, or materials furnished after the date specified. ______________________________ Signature of Lien Holder______________________________ Type or Print Name Unconditional Waiver and Release of Lien Page 2 of 2 COMMONWEALTH OF PENNSYLVANIA COUNTY 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: _____________________