Partial Unconditional Waiver Of Lien printable pdf download

PARTIAL UNCONDITIONAL WAIVER OF LIEN

My/Our contract with _____________________________________________________________

(other contracting party)

to provide _____________________________________________________________________

for the improvements to the property described as: _____________________________________

______________________________________________________________________________

hereby waive my/our construction lien rights to the amount of $____________________ for

labor/materials provided through_____________.

(date)

If the owner or lessee of the property or the owner’s or lessee’s designee has received a notice of

furnishing from me/one of us or if I/we are not required to provide one, and the owner, lessee or

designee has not received this waiver directly from me/one or us, the owner, lessee or designee

may not rely upon it without contacting me/one of us, either in writing, by telephone or personally,

to verify that it is authentic.

This waiver, together with all previous waivers, if any (check one) _____ does _____ does not

cover all amounts due me/us for contract improvement provided through the date as shown

above.

STATEMENT OF ACCOUNT:

Dated: __________________________

Contract Price $________________________

By: _____________________________

(Signature of Lien Claimant)

Previous Paid $________________________

________________________________

This Payment $________________________

(Printed Name of Lien Claimant)

Balance Due

$________________________

Address: ________________________

Labor Wages $________________________

Due but Unpaid

________________________________

Labor Fringe

$________________________

________________________________

Benefits & Withholdings Due but Unpaid

Telephone: _______________________

DO NOT SIGN BLANK OR INCOMPLETE FORMS - RETAIN A COPY.

Form No. PTC260

PUBLIC TITLE AGENCY

Partial Unconditional Waiver Of Lien