Fill and Sign the Upon the Undersigned Receiving Collected Funds in the Amount of Form

Conditional Waiver and Release of Lien Page 1 of 1 CONDITIONAL WAIVER AND RELEASE OF LIEN UPON FINAL PAYMENT On this _____ day of ________________, 20______, the undersigned lienor, 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 the following described property: _______________________________________________________________________________________________________________________________________________________________________________________________________________________. 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 STATE OF NEW HAMPSHIRE COUNTY OF _____________________ The instrument was acknowledged before me on ___________________ (date), by _________________________________________ (name(s) of persons). ______________________________ Signature of Notarial Officer (Seal, if any) Printed Name: _________________ Title and Rank:_________________ My Commission Expires: _____________________