Fill and Sign the Utah Conditional Waiver and Release Upon Final Form

Conditional Waiver and Release upon Final Payment Page 1 of 2 CONDITIONAL WAIVER AND RELEASE UPON FINAL PAYMENT- INDIVIDUAL Property Name: __________________________________ Property Location: _______________________________________________________ Undersigned's Customer: __________________________________ Invoice/Payment Application Number: _____________________________ Payment Amount: ________________________ Payment Period: ________________________ Amount of Disputed Claims: ________________________ Upon receipt by the undersigned of a check in the above-referenced Payment Amount payable to the undersigned, and when the check has been properly endorsed and has been paid by the bank on which it is drawn, this document becomes effective to release and the undersigned shall be deemed to waive 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 the final payment to the undersigned for all work, materials or equipment furnished by the undersigned to the Property or to the Undersigned's Customer and does not cover payment for Disputed Claims, if any. Before any recipient of this document relies on it, he or she should verify evidence of payment to the undersigned. The undersigned warrants that he or she either has already paid or will use the money he or she receives from the final 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 Conditional Waiver and Release upon Final Payment Page 2 of 2 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