Fill and Sign the Services Equipment or Material Furnished on the Job Form

Conditional Waiver and Release of Lien Upon Final Payment 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---------------------CONDITIONAL WAIVER AND RELEASE OF LIEN UPON FINAL PAYMENTOn 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: ________________________________________________________________________________________________________________________________________________ _______________________________________________________________________. This Conditional Waiver and Release of Lien Upon Final 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 covers the final payment to the undersigned for all labor, services, equipment, or material furnished on the job. Before any recipient of this document relies on it, the party should verify evidence of payment to the undersigned. ______________________________ Signature of Lien Holder ______________________________ Type or Print Name Conditional Waiver and Release of Lien Upon Final Payment Page 2 of 2STATE OF VERMONTCOUNTY OF _________________ On this _____ day of _______________, ___________, before me personally appeared ___________________________________ (name of person acknowledging) to me known to be the person who executed the foregoing instrument, and ____________________________________ he/she/they thereupon duly acknowledged to me that ___________________________________ he/she/they executed the same to be ___________________________________ his/her/their free act and deed. ______________________________Notary PublicPrint Name: ___________________ My commission expires: __________________