Job No.:

    Upon 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 is was drawn, this document becomes effective to release any mechanics’ lien, and state or federal statutory bond right, any private bond right, any claim for payment, any bonded stop notice, and any rights under any similar ordinance, rule or statue related to claim or payment rights for persons in the undersigned’s position that the undersigned has on the job of located at to the following extent. This release covers a progress payment for all labor, services, equipment or materials furnished to the jobsite or to through only and does not cover any retention, pending modifications and changes, or other items furnished after that date. Before any recipient of this document relies on it, that person should verify evidence of payment to the undersigned.

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

    Signed this day of ,


    Subscribed and sworn to before me this day of ,

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