Form Dep6077 - Payment Waiver Form (Page 2 of 2) in pdf

Form Dep6077 - Payment Waiver Form Page 2

DEP6077 (April 2011)

401 KAR 42:250

4. Notwithstanding any legal rights or remedies that Declarant may otherwise have, Declarant hereby declares, for itself and for its

heirs, successors; and assigns its sole legal recourse for non-payment of the Invoices shall be to proceed against the

Contractor. Declarant hereby waives forever any rights it may have to take legal action of any kind against the cabinet, or

against any person other than the Contractor, for non-payment of the Invoices.

5. Declarant hereby releases and discharges any and all liens it has filed, or will file, under KRS Chapte r 376 for work performed or

materials provided that are the subject of the Invoices. In the event any further documents are necessary to effectuate the

complete release and discharge of such liens, or to clear the title of the real property upon which suc h liens have been filed,

Declarant agrees to execute and return all such further documents within thirty (30) days after a written request made to

Declarant by the cabinet to do so.

IN WITNESS WHEREOF, Declarant has made and executed this Waiver as of the date first written above.

PRINTED NAME OF DECLARANT (Or Authorized Representative):

TITLE:

SIGNATURE OF DECLARANT (Or Authorized Representative):

DATE:

DECLARANT’S MAILING ADDRESS:

CITY:

STATE:

ZIP CODE:

DECLARANT’S TELEPHONE NUMBER:

AUTHORIZED REPRESENTIVE’S TELEPHONE NUMBER:

Subscribed and sworn to before me by:

This the:

day of:

SEAL

OPTIONAL

Notary Public

Commission State at Large:

OR County:

My commission expires:

If you have questions on how to fill out this form or to request a review of the facility records, please contact the USTB at (502)

564-5981or visit our website at

**RETAIN A COPY OF THIS FORM FOR YOUR RECORDS**

Page 2 of 2

Form Dep6077 - Payment Waiver Form Page 2