Fill and Sign the Ny Waiver Form

Conditional Waiver and Release of Lien Upon Progress Payment Page 1 of 2Prepared by, recording requested by and return to:Name: _____________________Company: _____________________Address:_______________________ City: ____________________State: _____Zip: _________Phone: _________________Fax: ___________________----------------------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: ________________________________________________________________________________________________________________________________________________ ___________________________________________________________________. 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 ______________________________ Type or Print Name Conditional Waiver and Release of Lien Upon Progress Payment Page 2 of 2STATE OF NEW YORKCOUNTY OF ___________________On the ____________ day of _________________ in the year __________ before me, the undersigned, personally appeared _____________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity (ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. ______________________________Notary PublicPrinted Name: _________________ My Commission Expires: _____________________