Copyright ©2005 Greater Illinois Title Company. All Rights Reserved. http://gitc.com/forms/
Compliments of Greater Illinois Title Company; for Internal and External Use.
Universal Doc Ref: GP_IEF0028-20050804-R1-0
WAIVER OF LIEN TO DATE
STATE OF ILLINOIS
Gty # _____________________
COUNTY OF
_____________________________
}
SS
Escrow # _____________________
TO WHOM IT MAY CONCERN:
WHEREAS the undersigned has been employed by ____________________________________________________________________
to furnish _____________________________________________________________________________________________________
for the prem
ises known
as ________________________________________________________________________________________
of which ___________________________________________________________________________________________ is the owner.
THE
undersigned, for and
in consideration of ________________________________________________________________________
______________________________________________________________________________ ($ __________________________)
Dollars,
and other good and valuable considerations, the receipt whereof is hereby acknowledged, do(es) hereby waive and release any
and all lien
or claim of, or right to, lien, under the statutes of the State of Illinois, relating to mechanics’ liens, with respect to and on said
above-described premise
s, and the improvements thereon, and on the material, fixtures, apparatus or machinery furnished, and on the
moneys, fun
ds or other considerations due or to become due from the owner, on account of all labor, services, material, fixtures,
apparatus or machinery,
furnished to this date by the undersigned for the above-described premises, INCLUDING EXTRAS.*
DATE ____________________________ COMPANY
NAME ________________________________________________________
ADDRESS ________________________________________________________________
SIGNATURE AND TITLE _______________________________________________________________
* EXTRAS INLCUDE BUT ARE NOT LIMITED TO CHANGE ORDERS, BOTH ORAL AND WRITTEN, TO THE CONTRACT.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------
STATE OF ILLINOIS
COUNTY OF _____________________________
}
SS
CONTRACTOR’S AFFIDAVIT
TO WHOM IT MAY CONCERN:
THE UNDERSIGNED, (NAME) ____________________________________________ BEING DULY SWORN,
DEPOSES
AND SAYS THAT HE OR SHE IS (POSITION) __________________________________________________________________ OF
(COMPANY NAME) _______________________________________________________________________________ W
HO IS THE
CONTRACTOR
FURNISHING __________________________________________________________ WORK ON THE BUILDING
LOCATED AT ________________________________________________________________________________________________
OWNED BY __________________________________________________________________________________________________
That the
total amount
of the contract including extras* is $______________________________ on which he or she has received
payment of $ __________________________ prior to this payment. That all waivers are true, correct and genuine and delivered
uncondition
ally and that there is no claim either legal or equitable to defeat the validity of said waivers. That the following are the names
and addresses of all
parties who have furnished material or labor, or both, for said work and all parties having contracts or sub contracts
for specific portions of said wor
k or for material entering into the construction thereof and the amount due or to become due to each, and
that the items mentioned includ
e all labor and material required to complete said work according to plans and specifications:
NAMES AND ADDRESSES WHAT FOR
CONTRACT PRICE
INCLDG EXTRAS*
AMOUNT
PAID
THIS
PAYMENT
BALANCE
DUE
TOTAL LABOR AND MATERIAL INCLUDING EXTRAS* TO COMPLETE
That there are no other contacts for said work outstanding, and that there is nothing due or to become due to any person for material,
labor or other work of any kind done or to be done upon or in connection with said work other than above stated.
DATE ___________________________ S
IGNATURE _______________________________________________________
SUBSCRIBED AND SWORN TO BEFORE ME THIS _______________ DAY OF ___________________________,________,
*EXTRAS INCLUDE BUT ARE NOT LIMITED TO CHANGE
ORDERS, BOTH ORAL AND WRITTEN, TO THE CONTRACT.
__________
______________________________________
NOTARY PUBLIC
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