Fill and Sign the Unconditional Progress Payment 497320722 Form

UNCONDITIONAL WAIVER AND RELEASE UPON PROGRESS PAYMENT- INDIVIDUAL Property Name: __________________________________ Property Location: _______________________________________________________ Undersigned's Customer: __________________________________ Invoice/Payment Application Number: _____________________________ Payment Amount: ________________________ The undersigned has been paid and has received a progress payment in the above-referenced Payment Amount for all work, materials and equipment the undersigned furnished to his or her Customer for the above-described Property and does hereby waive and release any notice of lien, any private bond right, any claim for payment and any rights under any similar ordinance, rule or statute related to payment rights that the undersigned has on the above — described Property to the following extent: ________________________________________________________________________ _______________________________________________________________________ . This release covers a progress payment for the work, materials and equipment furnished by the undersigned to the Property or to the Undersigned's Customer which are the subject of the Invoice or Payment Application, but only to the extent of the Payment Amount or such portion of the Payment Amount as the undersigned is actually paid, and does not cover any retention withheld, any items, modifications or changes pending approval, disputed items and claims, or items furnished that are not paid. The undersigned warrants that he or she either has already paid or will use the money he or she receives from this progress payment promptly to pay in full all his or her laborers, subcontractors, materialmen and suppliers for all work, materials or equipment that are the subject of this waiver and release. This the _____ day of _______________ , 20 ______ . ______________________________ Signature _____ _________________________ Type or Print Name Notice: This document waives rights unconditionally and states that you have been paid for giving up those rights. This document is enforceable against you if you sign it to the Unconditional Waiver and Release upon Progress Payment Page 1 of 2 extent of the Payment Amount or the amount received. If you have not been paid, use a conditional releasee form. This the _____ day of _______________ , 20 ______ . ______________________________ Signature _____ _________________________ Type or Print Name State of Nevada County of __________________ This instrument was acknowledged before me on ____________ by __________________________________ . _________________________ (Signature of notarial officer) (Seal, if any) _________________________ (Title and rank (optional)) (My commission expires (optional): _____________ ) Certificate of Delivery I, ___________________________________ , hereby certify that I have delivered this day a true and correct copy of the foregoing to _________________________________ by: ( ) Personal Service ( ) Mailing a true and correct copy of same by certified U.S. mail, postage prepaid, return receipt requested to __________________________________ . So certified this the _____ day of ______________ , 20 ______ . ________________________ Signature Unconditional Waiver and Release upon Progress Payment Page 2 of 2