Fill and Sign the Release Claim Lien Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ___________________ Address: ____________________ City: ___________________ State: _____ Zip: __________ Phone: _________________ Fax: __________________ 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 This instrument was prepared by _______________ . STATE OF WEST VIRGINIA COUNTY OF ________________ This instrument was acknowledged before me on ________________ (date) by _________________________________ (name or names of person or persons acknowledging). _________________________ Notary Public Printed Name: ____________________ My Commission Expires: _______________