Fill and Sign the On This Day of 20the Undersigned Lienor 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: __________________----------------------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 Page 2 of 2STATE OF NORTH DAKOTACOUNTY OF ________________The foregoing instrument was acknowledged before me this _____ day of ________________, 20______ by ________________________________ (name of person acknowledging). _____________________________Notary Public Printed Name: _________________ My Commission Expires: ________________