Fill and Sign the Ny Waiver 497321338 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _____________________ Company: _____________________ Address: _______________________ City: ____________________ State: _____ Zip: _________ Phone: _________________ Fax: ___________________ 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 1 of 2 STATE OF NEW YORK COUNTY 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 Public Printed Name: _________________ My Commission Expires: _____________________ Conditional Waiver and Release of Lien Upon Progress Payment Page 2 of 2