Fill and Sign the On This Day of 20 Before Me 490218618 Form

Unconditional Waiver and Release of Lien Page 1 of 2Prepared 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 FINAL PAYMENT On this _____ day of ________________ , 20______, the undersigned lienor, whose address is ______________________________________________________________________, in consideration of the final payment in the amount 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: ________________________________________________________________________________________________________________________________________________ _______________________________________________________________________. ______________________________ Signature of Lien Holder ______________________________ Type or Print Name Unconditional Waiver and Release of Lien Page 2 of 2State of South DakotaCounty of __________________On this ______ day of __________________ , 20______, before me, ______________________________, 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/she executed the same for the purposes therein contained.In witness whereof I hereunto set my hand and official seal.Notary Public, State of My commission expires: Type or Print Name