Receipt And Partial Release Of Lien printable pdf download

RECEIPT AND PARTIAL RELEASE OF LIEN

The undersigned representative of__________________________, at _____________________,

hereby acknowledges the receipt of the sum of ____________________________

($__________), which sum constitutes $____________, less retainage of $____________, for

materials, labor and/or services furnished to Southland Contracting, Inc., for the project known

as:

located at:

hereby releases Southland Contracting, Inc., the Owner, and their respective insurers, bonding

companies, successors and assigns from any further liability and waive any lien and any right to

lien for the furnishing of materials, labor or services for the project through and including

______________________; and certifies that all materials, labor and services performed by the

undersigned have been paid in full and that the premises of the project described above cannot be

made the subject of any valid lien or claim by any person, entity, firm or corporation who

furnished to the undersigned any material, labor or services used in the improvements to the

above-described premises through and including ________________.

Executed this ____ day of _____________, ______.

_________________________________

(Printed name of person/entity receiving payment)

_________________________________

(Signature)

____________________________________________

(Office, position or capacity of person signing)

State of Florida

County of _______________

The foregoing instrument was acknowledged before me by _______________________, as ___________________

of _______________________, and who is personally known to me or produced the following form of

identification __________________; and is known to be the person described in and who executed the foregoing

instrument, and acknowledged to and before me that he/she executed said instrument for the purposes therein

expressed and the aforementioned officer acknowledged executing the same for such corporation, freely and

voluntarily, under authority duly vested by said corporation, and that an oath ( was/ was not) taken.

Witness my hand and official seal this __________ day of _______________, ______.

____________________________________

NOTARY PUBLIC

My Commission Expires:

This is a statutory form prescribed by Section 713.20, Florida Statutes (2001)

Receipt And Partial Release Of Lien