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
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)
(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 _______________, ______.
My Commission Expires:
This is a statutory form prescribed by Section 713.20, Florida Statutes (2001)


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