Fillable Borrower'S Release And Request For Payment printable pdf download

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

(property address)

funds to _______________________________________________________ in the amount of

(contractor/payee/customer only)

$_____________________________for partial/final payment of work, labor, services and/or furnished materials

($ amount must be filled in)

(circle one)

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.

___________________________________________________

___________________________

(Borrower’s Signature)

(Date)

(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

(Date)

_____________________________________________________________

PARTIAL/ FINAL

(Name of Company/Contractor)

(circle one)

BY: __________________________________________________________

(Signature)

____________________________________________________________

(Please print name and Title)

(Tax ID# or SS#)

____________________________________________________________

___________________________

(Address)

(Telephone number)

Office Use Only:

Approving Inspector: ___________________________

Date: _______________________

OK TO PAY

Borrower'S Release And Request For Payment

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