7/1/12

CONDITIONAL WAIVER AND RELEASE ON FINAL PAYMENT

NOTICE: THIS DOCUMENT WAIVES THE CLAIMANT'S LIEN, STOP PAYMENT

NOTICE, AND PAYMENT BOND RIGHTS EFFECTIVE ON RECEIPT OF PAYMENT.

A PERSON SHOULD NOT RELY ON THIS DOCUMENT UNLESS SATISFIED THAT

Job Location:

Owner:

Thisdocument waives and releases lien,stop paymentnotice, and paymentbond rights the claimant has

for labor and service provided, and equipment and material delivered, to thecustomeron this job. Rights

based upon labor or service provided,or equipment or material delivered, pursuant to awritten change

order thathas been fully executedby the parties prior to the date that this documentis signed by the

claimant, arewaived and released by this document, unless listed as an Exception below. This document

is effective only on the claimant'sreceiptof paymentfrom the financial institutionon which the following

Thisdocument does not affect any of the following:

Disputed claims for extras in the amount of:$

Claimant'sSignature:

Claimant's Title:

Date of Signature: