Southern Illinois University Final Waiver Form
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1
2SOUTHERN ILLINOIS UNIVERSITY
FINAL
WAIVER OF LIEN TO DATE
Waiver of Lien No.
STATE OF
)
COUNTY OF
) SS
TO WHOM IT MAY CONCERN:
Whereas the undersigned has been employed by
SIU Contract No.
Contractor's Contract No.
To furnish for the premise known as
Project:
Project No.:
of which the State of Illinois, acting through Southern Illinois University 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 Liens Against Public Funds on the
monies, bonds or warrants due or to become due from the State, on account of labor, services, material, fixtures, apparatus or
machinery heretofore furnished, or which may be furnished at any time hereafter, by the undersigned for the above-described
premises.
Given under
hand and seal
this
day of
,
(Affix Corporate Seal Here)
(Company Name)
ATTEST:
(Signature)
(Signature of Secretary of Corporation)
ITS:
(SEAL)
(Title)
NOTE: All waivers must be for the full amount paid. If waiver is for a corporation, name should be used, corporate seal affixed
and title of officer signing waiver should be set forth; if waiver is for a partnership, the partnership name should be used, partner
should sign and designate himself as partner.
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