Acknowledgement Of Payment And Waiver Of Lien
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1Form D
SUPPLIER/SUB-CONTRACTOR CERTIFICATE AND WAIVER OF LIEN
ACKNOWLEDGEMENT OF PAYMENT
SUPPLIER/SUB-CONTRACTOR: _______________________________________
PROJECT:
_____________________________________________
ADDRESS:
_____________________________________________
OWNER:
_____________________________________________
PRIME CONTRACTOR:
_____________________________________________
PERIOD FROM:
____________________ TO _____________________
DATE
DATE
Materials, Equipment and /or Machinery have been delivered to the site, materials have been
especially fabricated, or labor has been completed for the demolition of and/or for the construction of
improvements for the Project during the Period as follows:
Description:
$ _________________ AMOUNT PAID
______________________ hereby certifies that payment has been made and hereby waives all right
to liens and claims against the Owner and ___________________________ therefore.
By:
____________________________
Title:
____________________________
Date:
____________________________
SWORN TO BEFORE ME AND SUBSCRIBED IN MY PRESENCE AT _____________, _______.
CITY
STATE
THIS _______ DAY OF ______________________, 20_____.
__________________________________________________
NOTARY
CONTRACTOR:
___________________________________________
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Parent category: Legal