Fill and Sign the Vermont Waiver Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _____________________ Company: _____________________ Address: _______________________ City: ____________________ State: _____ Zip: _________ Phone: _________________ Fax: ___________________ CONDITIONAL WAIVER AND RELEASE OF LIEN UPON PROGRESS PAYMENT On this _____ day of ________________ , 20 ______ , the undersigned lienor, whose address is ______________________________________________________________________ , in consideration of the sum of $ ___________________ , does hereby waive and release 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 property located at and described as: ________________________________________________________________________ ________________________________________________________________________ ___________________________________________________________________ . This Conditional Waiver and Release of Lien Upon Progress 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 does not cover any retention or labor, services, or materials furnished after the date specified. ______________________________ Signature of Lien Holder _____ _________________________ Type or Print Name Conditional Waiver and Release of Lien Upon Progress Payment Page 1 of 2 STATE OF VERMONT COUNTY OF _________________ On this _____ day of _______________ , ___________ , before me personally appeared ___________________________________ (name of person acknowledging) to me known to be the person who executed the foregoing instrument, and ____________________________________ he/she/they thereupon duly acknowledged to me that ___________________________________ he/she/they executed the same to be ___________________________________ his/her/their free act and deed. ______________________________ Notary Public Print Name: ___________________ My commission expires: __________________ Conditional Waiver and Release of Lien Upon Progress Payment Page 2 of 2