Partial Waiver And Affidavit printable pdf download

PARTIAL WAIVER OF LIEN AND CONTRACTOR’S AFFIDAVIT



STATE OF ILLINOIS

Escrow # _____________________

COUNTY OF

Guarantee # ___________________

TO WHOM IT MAY CONCERN:

WHEREAS the undersigned has been employed by __________________________________________________________________

to furnish __________________________________________________________________________________________________

for the premises know as ______________________________________________________________________________________

of which _________________________________________________________________________________________ is the owner.

THE undersigned, for and in consideration of _______________________________________________________________

($______________________) Dollars, and other good and valuable consideration, the receipt whereof is hereby acknowledged, do(es)

hereby waive and release any and all lien or claim of, or right to, lien, under the State of Illinois relating to mechanics’ liens, with

respect to and on said above-described premises, and the improvements thereon, and on the material, fixtures, apparatus or machinery

furnished, and on the moneys, funds or other considerations due or to become due from the owner, on account of labor, services,

material, fixtures, apparatus or machinery heretofore furnished TO THIS DATE by the undersigned for the above-described premises,

INCLUDING EXTRAS*.

That the total amount of the contract including extras * is $ ________________________ on which he or she has received payment of

$ ___________________ prior to this payment. That all waivers are true, correct and genuine and delivered unconditionally and that

there is no claim either legal or equitable to defeat the validity of said waivers. THAT THE FOLLOWING ARE THE NAMES

AND ADDRESSES OF ALL PARTIES WHO HAVE FURNISHED OR WILL FURNISH MATERIAL OR LABOR, OR

BOTH, FOR SAID WORK and the amount due or to become due to each, and that the items mentioned include all labor and

material required to complete said work according to plans and specifications:

CONTRACT

AMOUNT

THIS

BALANCE

NAMES AND ADDRESSES

WHAT FOR

PRICE INCLDG

PAID

PAYMENT

DUE

EXTRAS *

TOTAL LABOR AND MATERIAL INCLUDING EXTRAS * TO COMPLETE

*EXTRAS INCLUDE BUT ARE NOT LIMITED TO CHANGE ORDERS, BOTH ORAL AND WRITTEN, TO THE CONTRACT.

That there are no other contracts for said work outstanding, and that there is nothing due or to become due to any person for material,

labor or other work of any kind done or to be done upon or in connection with said work other than above stated.

COMPANY NAME____________________________________________

ADDRESS___________________________________________________

CITY, STATE, ZIP____________________________________________

DATED:____________________

__________________________________________________

SIGNATURE AND TITLE

SUBSCRIBED AND SWORN TO BEFORE ME THIS ________ DAY OF ____________________, 20______

__________________________________________________

NOTARY PUBLIC

Provided by Ticor Title Insurance Company

12/00

Partial Waiver And Affidavit

Related Articles

Related forms

Related Categories