Fill and Sign the Materials Furnished After the Date Specified Form

Unconditional Waiver and Release of Lien Upon Progress Payment Page 1 of 2 Prepared by, recording requested by and return to: Name: ___________________ Company: ___________________ Address: ____________________ City: ___________________ State: _____ Zip: __________ Phone: _________________ Fax: __________________ ----------------------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: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. 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 Upon Progress Payment Page 2 of 2 STATE OF WYOMING COUNTY OF __________________ This instrument was acknowledged before me on the ______ day of ______________, 20______, by __________________________________ (name(s) of person(s)). ___________________________________ (Seal, if any) (Signature of notarial officer) ___________________________________ Title (and Rank) My Commission Expires:__________________