7/1/12
CONDITIONAL WAIVER AND RELEASE ON PROGRESS 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
THE CLAIMANT HAS RECEIVED PAYMENT.
Identifying Information
Name of Claimant:
Name of Customer:
Job Location:
Owner:
Through Date:
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 through
the Through Date of this document. 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:
Amount of Check: $
Check Payable to:
Exceptions
This document does not affect any of the following:
(1) Retentions.
(2) Extras for which the claimant has not received payment.
(3) The following progress payments for which the claimant has previously given a conditional waiver
and release but has not received payment:
Date(s) of waiver and release:________________________________________
Amount(s) of unpaid progress payment(s): $_____________________________
(4) Contract rights, including (A) a right based on rescission, abandonment, or breach of
contract, and (B) the right to recover compensation for work not compensated by the payment.
Signature
Claimant's Signature:
Claimant's Title:
Date of Signature:
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