Fill and Sign the Waiver and Release of Lien Upon Final 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: __________________ Name of Claimant: ________________________________ Name of Debtor: ________________________________ Amount of Lien: _________________ Tax Assessor’s Account Number: _________________ Situs Address of Real Property: ________________________________________________________________________ CONDITIONAL 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: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ (legal description that includes a metes and bounds description; a lot, block, subdivision; the book and page and/or instrument number of a recorded deed where the legal can be found; or a parcel in a partition) . 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. Conditional Waiver and Release of Lien Page 1 of 2 ______________________________ Signature of Lien Holder _____ _________________________ Type or Print Name STATE OF OREGON COUNTY OF _________________ This instrument was acknowledged before me on _______________________ (date) by __________________________________________ (name(s) of person(s)). ______________________________ NOTARY PUBLIC Print Name: ___________________ My Commission Expires: ____________________ Conditional Waiver and Release of Lien Page 2 of 2