Form G - Supplier Final Unconditioal Waiver Of Lien Rights
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1Form G
SUPPLIER FINAL UNCONDITIOAL WAIVER OF LIEN RIGHTS
Supplier:
Sub-Contractor:
Project Name/Location:
Balance Due to Supplier:
Zero, $0.00
The undersigned, for and in consideration of the payments made to it by the Subcontractor, or to a subcontractor,
materialman or supplier of the undersigned, for labor, services, materials, fixtures, apparatus and/or equipment
furnished for the Project, warrants, represents and guarantees the following:
1. The undersigned has received payment in full, for all labor, services, materials, fixtures, apparatus, and/or
equipment furnished in the construction of the Project and there are no outstanding claims against
________________________ and/or its surety, or the Subcontractor in connection with the Project.
2. All labor, services, materials, fixtures, apparatus, and/or equipment, and all applicable taxes, fees and
benefits, have been paid for in full and the undersigned shall indemnify and hold harmless the Owner,
________________________, its surety, and the Subcontractor from any and all claims for payment.
3. The undersigned hereby waives, releases and dissolves any mechanics liens or rights of lien it has or may
have on the Project, including the real estate and the improvements thereon, on account of labor, services,
materials, fixtures, apparatus and/or equipment furnished for the Project.
4. The undersigned hereby releases, remises and discharges the Owner and ________________________ and
its surety from all claims, debts, demands, liabilities and damages it ever had, now has or ever may have,
arising out of or relating in any way to the undersigned’s agreement with the Subcontractor and or
furnishing labor, services, materials, fixtures, apparatus, and/or equipment in the construction of the Project.
SUPPLIER: _______________________________
By:
_____________________________________
Name: _____________________________________
Title: _____________________________________
STATE OF
_______________
COUNTY OF
_______________
Sworn to before me and subscribed in my presence by
__
___ , the
(Title)
of
______ (Supplier), on this _____ day of _________________, 20______.
________________________________________
Notary Public
My Commission Expires: ____________________
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