Fill and Sign the Kansas Waiver Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: Company: Address: City: State: Zip: Phone: Fax: RELEASE OF NOTICE OF INTENT TO PERFORM NO. ______ AND WAIVER OF LIEN—INDIVIDUAL I, ____________________________________, (name of supplier, subcontractor or contractor) of _________________________________________________________, (address of supplier, subcontractor or contractor) do hereby acknowledge that I filed Notice of Intent to Perform No. ______ covering property owned by ________________ ________________ (name of property owner), and having the legal description as follows: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. In consideration of the sum of $______________, the receipt of which is hereby acknowledged, I hereby direct the clerk of the district court of ______________, Kansas to release the subject Notice of Intent to Perform and do hereby waive and relinquish any statutory right to a lien for the furnishing of labor, equipment, materials or supplies to the above-described real estate under the statutes of the state of Kansas. This the ____ day of ____________________, 20____. ______________________________ Signature KS § 60-1103b(c) Release of Notice of Intent to Perform Page 1 of 2 Acknowledgment of Individual STATE OF KANSAS COUNTY OF ___________________ This instrument was acknowledged to me on _______________________________ (date) by ________________________________ [name(s) of person(s)]. ______________________________ Notary Public Print Name: ___________________ My commission expires: ___________________ Release of Notice of Intent to Perform Page 2 of 2