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Identifying Information
| Name of Claimant: Name |
| Name of Customer: Name |
| Job Location: Street address , City , State ZIP Code |
Owner(s): Name and Yes / No Name and Yes / No Name and Yes / No Name |
Conditional Waiver and Release
This document waives and releases lien, stop payment notice, and payment bond rights the claimant has for labor and service provided, and equipment and material delivered, to the customer on this job. Rights based upon labor or service provided, or equipment or material delivered, pursuant to a written change order that has been fully executed by the parties prior to the date that this document is signed by the claimant, are waived and released by this document, unless listed as an Exception below. This document is effective only on the claimant's receipt of payment from the financial institution on which the following check is drawn:
| Maker of Check: Name |
| Amount of Check: $ $ Amount |
| Check Payable to: Name(s) |
| Exceptions |
This document does not affect any of the following: Yes / No Description Disputed claims for extras in the amount of: $ $ Amount |
| Signature |
| Claimant's Signature: |
| Claimant's Title: Yes / No Title |
| Date of Signature: |