Project: ________________________

Job No.: ________________

On receipt by the undersigned of a check from __________________________, in the (Maker of Check)

sum of $ payable to , and when the check has

(Amount) (Payee(s) of Check)

been properly endorsed and has been paid by the bank on which it is drawn, this document becomes effective to release any Mechanic’s Lien, any state or federal statutory bond right, any private bond right, any claim for payment and any rights under any similar ordinance, rule or statute related to claim or payment rights for persons in the undersigned’s position that the undersigned has on the job of

______________________ located at ____________________________________

(Owner) (Job Description)

to the following extent. This release covers a progress payment for all labor, services, equipment or materials furnished to the job site or to ___________________________ (Person with whom undersigned contracted)

through only and does not cover any retention pending modifications and

(Date)

changes or items furnished after that date. Before any recipient of this document relies on it, that person should verify evidence of payment to the undersigned.

The undersigned warrants that he either has already paid or will use the monies he receives from this progress payment to promptly pay in full all of his laborers, subcontractors, materialmen and suppliers for all work, materials, equipment or services provided for or to the above-referenced project up to the date of this waiver.

DATED:

(Company Name)

By:

(Signature)

(Title)