Fill and Sign the Waiver Payment Sample Form

Waiver and Release of Lien Page 1 of 2 Prepared by, recording requested by and return to: ---------------------- Above this Line for Official Use Only --------------------- Name: ___________________ Company: ___________________ Address: _____________________ City: __________________________ State: _____ Zip: _____________ Phone: _____________________ Fax: _______________________ WAIVER AND RELEASE OF LIEN UPON PROGRESS PAYMENT - INDIVIDUAL The undersigned lienor, in consideration of the sum of $ __________________ , hereby waives and releases its 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 waiver and release does not cover any retention or labor, services, or materials furnished after the date specified. DATED on _____ day ___________________ , 20 _____ . Lienor's Name _________________________ Address ______________________________ By _________________________ Printed Name _____ _____________________ Waiver and Release of Lien Page 2 of 2 STATE OF ___________ COUNTY OF _____________ Sworn to (or affirmed ) and subscribed before me this _____ day of _________________, 20______ by _________________________ (name of person making statement) who is personally known to me or produced _________________________ as identification, and who did take an oath. ____ ________________________ NOTARY PUBLIC Printed Name of Notary _________________________ Commission Expires _________________________