Fill and Sign the On This Day of 20 the Undersigned Lienor in Consideration of the Sum of Does Hereby Waive and Release His or Her Lien and Right Form

Conditional Waiver and Release of Lien Upon Progress Payment On this _____ day of ________________ , 20 ______ , the undersigned lienor, 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 following described property: ________________________________________________________________________ ________________________________________________________________________ ___________________________________________________________________ . 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 STATE OF MISSISSIPPI COUNTY OF _________________ Personally appeared before me, the undersigned authority in and for said county and state, on this ______ day of __________________ , 20 ______ , within my jurisdiction, the within named ______________________________ , who acknowledged that he/she/they executed the above and foregoing instrument. Notary Public My commission expires:       Type or Print Name Conditional Waiver and Release of Lien Page 1 of 1