Contractor Lien Waiver Form
Date:
_______________________
County:
_______________________
State:
_______________________
Customer Name:
________________________________________
Customer Phone:
________________________________________
Customer Address:
_______________________________________________________________
Job Address:
_______________________________________________________________
Contractor Name:
________________________________________
Contractor Address:
_______________________________________________________________
Contractor Phone:
________________________________________
Payments Rec’d To Date:
$ _______________________________
Payment Received TODAY:
$ _______________________________
(Lien release is contingent on the contractor receiving this payment)
The Contractor signing below acknowledges receipt of all payments stated above. These payments are in compliance with the written
contract between the parties above. The Contractor signing below hereby states payments for all work done to this date has been paid
in full.
The Contractor signing below releases and relinquishes any and all rights available to place a mechanics or material man lien against
the subject property for the above described work. All parties agree that all work performed to date has been paid for in full and in
compliance with their written agreement.
The undersigned Contractor releases the Customer for any liability from non‐payment of material or services extended through this date.
The undersigned contractor has read this entire agreement and understands the agreement.
Contractor:
Date:
_____________________________________
__________________________