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{waiver_type_display} LIEN WAIVER
LIEN WAIVER
State of
Date:
Waiver Type:
SECTION 1: PARTIES
CLAIMANT:
Name: ________________ (________)
Address: ________________, ________, ____ _____
Phone: ___________
Name: ________________ (________)
Address: ________________, ________, ____ _____
Phone: ___________
PROPERTY OWNER:
Name: ________________ (________)
Address: ________________, ________, ____ _____
Phone: ___________
Name: ________________ (________)
Address: ________________, ________, ____ _____
Phone: ___________
SECTION 2: PROPERTY DESCRIPTION
Address: ________________, ________, ____ _____Project: ________________
SECTION 3: PAYMENT INFORMATION
Payment Amount: $________Total Contract Amount: $________
SECTION 4: SIGNATURES
CLAIMANT CERTIFICATION:The undersigned certifies under penalty of perjury that the foregoing statements are true and correct to the best of the undersigned's knowledge and belief.
CLAIMANT SIGNATURE:
_________________________________ Date: ____________
[claimant name]
Title: _________________________ (if applicable)
Frequently Asked Questions
{waiver_type_display} LIEN WAIVER