Fill and Sign the Pennsylvania Waiver 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: ________________________________________________________________________________________________________________________________________________ _______________________________________________________________________ (address should include municipality, ward (if in the city of Pittsburgh), county and state) (legal description should include a metes and bounds description; a lot, block, subdivision; the book and page and/or instrument number of a recorded deed where the legal can be found; or a parcel in a partition). ______________________________ Signature of Lien Holder ______________________________ Type or Print Name Unconditional Waiver and Release of Lien Page 2 of 2COMMONWEALTH OF PENNSYLVANIACOUNTY OF _________________ On this, the ___ day of __________, 20____, before me a notary public, 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 executed the same for the purposes therein contained. In witness hereof, I hereunto set my hand and official seal. ___________________________ Notary Public ___________________________ Printed Name (Stamp or Seal)________________My Commission Expires: _____________________