BORROWER’S RELEASE AND REQUEST FOR PAYMENT
This section to be completed by borrower
I, ________________________________________________________ as owner of the property located at
(please print your name)
____________________________________________, hereby authorize Neighborhood Finance Corporation to disburse
funds to _______________________________________________________ in the amount of
$_____________________________for partial/final payment of work, labor, services and/or furnished materials
($ amount must be filled in)
described as follows:
(list all items)
and hereby agree to hold Neighborhood Finance Corporation harmless and hereby release Neighborhood Finance Corporation
from any and all claims that I may have against Neighborhood Finance Corporation arising from or relating in any way to the
payment I have hereby authorized.
(Daytime Telephone #)
Waiver to be completed by contractor/payee when check picked up
WAIVER OF MECHANIC’S LIEN
STATE OF IOWA, COUNTY OF POLK
The undersigned has been employed by the aforesaid homeowner to furnish labor, services and/or materials for construction,
repair, and/or improvements to the aforesaid property. That said Company or person, has received payment as set out above, and
has been paid by the Neighborhood Finance Corporation at the request of said homeowner.
For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the undersigned does hereby
waive and release any and all liens and rights to file and establish a mechanic’s lien against the above building and improvements,
and the above described premises, for labor or materials, or both, furnished by the undersigned through the date of this waiver.
The undersigned represents that no other person or party has any right to a lien on the above property on account of work
performed or materials furnished to the undersigned by virtue of a contract or purchase order with the homeowner.
Executed and check # ______________ received this date: _______________________at Des Moines, Iowa
(Name of Company/Contractor)
(Please print name and Title)
(Tax ID# or SS#)
Office Use Only:
Approving Inspector: ___________________________
OK TO PAY