Project:

On receipt by the undersigned of a check from in the sum of $ payable to , 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 any mechanic’s lien, any state or federal statutory bond right, any private bond right, any claim for payment and any rights under any similar ordinance, rule or statute related to claim or payment rights for persons in the undersigned’s position, the undersigned has on the job of located at . This release covers the final payment to the undersigned for all labor, services, equipment or materials furnished to the jobsite or to except for disputed claims in the amount of . Before any recipient of this document relies on it, the person should verify evidence of payment to the undersigned.

The undersigned warrants that he either has already paid or will use the monies he receives from this final payment to promptly pay in full his laborers, subcontractors, materialmen and suppliers, equipment or services provided for or to the above referenced project up to the date of this waiver.


Signed this day of ,

Signature:

Subscribed and sworn to before me this day of ,

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