Fill and Sign the South Dakota Payment Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ___________________ Address: ____________________ City: ___________________ State: _____ Zip: __________ Phone: _________________ Fax: __________________ UPI Number: ________________ 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: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . ______________________________ Signature of Lien Holder _____ _________________________ Type or Print Name Unconditional Waiver and Release of Lien Page 1 of 2 State of South Dakota County of __________________ On this ______ day of __________________ , 20 ______ , before me, ______________________________ , 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/she executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal. Notary Public, State of       My commission expires:       Type or Print Name Unconditional Waiver and Release of Lien Page 2 of 2