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Identifying Information
| Name of Claimant: Name |
| Name of Customer: Name |
| Job Location: Street address , City , State ZIP Code |
| Owner: Name and Yes / No Name and Yes / No Name and Yes / No Name |
| Through Date: Date |
Unconditional Waiver and Release
This document waives and releases lien, stop payment notice, and payment bond rights the claimant has for labor and service provided, and equipment and material delivered, to the customer on this job through the Through Date of this document. Rights based upon labor or service provided, or equipment or material delivered, pursuant to a written change order that has been fully executed by the parties prior to the date that this document is signed by the claimant, are waived and released by this document, unless listed as an Exception below. The claimant has received the following progress payment: $$ Amount .
Exceptions
| This document does not affect any of the following: (1) Retentions. (2) Extras for which the claimant has not received payment. (3) Contract rights, including (A) a right based on rescission, abandonment, or breach of contract, and (B) the right to recover compensation for work not compensated by the payment. |
Signature
| Claimant's Signature: |
| Claimant's Title: Yes / No Title |
| Date of Signature: |