Fill and Sign the Should These Funds Not Be Received within Days of Form

Conditional 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---------------------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 Page 2 of 2STATE OF RHODE ISLANDCOUNTY OF __________________ In ___________________________________ in said county on the _____ day of _______________, 20_____, before me personally appeared _________________________________ each and all to me known and known by me to be the party(ies) executing the foregoing instrument, and __________________________________ acknowledged said instrument, by ___________________________________ executed to be ________________________________ free act and deed. ______________________________ NOTARY PUBLIC Print Name: ___________________ My Commission Expires: ________________