Final Sales Tax Affidavit Page 7
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10CONDITIONAL
WAIVER AND RELEASE OF LIEN
UPON FINAL PAYMENT
The undersigned lienor, in consideration of the final payment in the amount
of $__________________, hereby waives and releases its lien and right to claim a lien for labor,
services or materials furnished to Summit Contractors Group, Inc. on the job of
_______________________ , to the following described property:
Job Name:
Street Address
City, State Zip:
This release is contingent upon receipt by the undersigned of the consideration specified
above and upon full collection by the undersigned of any and all checks, drafts and instruments
given in payment for labor, services or material on the job.
DATED on ___________________________, 20_____.
___________________________________
(Subcontractor’s Name)
By: _______________________________
Printed Name________________________
STATE OF FLORIDA
COUNTY OF ___________________
The foregoing instrument was acknowledge before me this___________ day of
______________, 20__, by______________________________, as ______________________
of ______________________________, who is:
(Subcontractor’s Name)
_________Personally known
_________Produced Identification
Type of Identification Produced____________________
___________________________________
NOTARY PUBLIC
My Commission Expires_______________
NOTE:
This is a statutory form prescribed by Section 713.20, Florida Statutes
(2001).
Return to: Summit Contractors Group, Inc., 6877 Phillips Industrial Boulevard, Jacksonville, Florida 32256
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