WAIVER OF LIEN TO DATE
STATE OF ILLINOIS |
} SS |
Gty # _____________________ |
COUNTY OF _____________________________ |
Escrow # _____________________ |
TO WHOM IT MAY CONCERN:
WHEREAS the undersigned has been employed by ____________________________________________________________________
to furnish _____________________________________________________________________________________________________
for the premises known as ________________________________________________________________________________________
of which ___________________________________________________________________________________________ is the owner.
THE undersigned, for and in consideration of ________________________________________________________________________
______________________________________________________________________________ ($ __________________________)
Dollars, and other good and valuable considerations, the receipt whereof is hereby acknowledged, do(es) hereby waive and release any and all lien or claim of, or right to, lien, under the statutes of the State of Illinois, relating to mechanics’ liens, with respect to and on said above-described premises, and the improvements thereon, and on the material, fixtures, apparatus or machinery furnished, and on the moneys, funds or other considerations due or to become due from the owner, on account of all labor, services, material, fixtures,
apparatus or machinery, furnished to this date by the undersigned |
for the above-described premises, INCLUDING EXTRAS.* |
DATE ____________________________ COMPANY NAME |
________________________________________________________ |
ADDRESS ________________________________________________________________
SIGNATURE AND TITLE _______________________________________________________________
* EXTRAS INLCUDE BUT ARE NOT LIMITED TO CHANGE ORDERS, BOTH ORAL AND WRITTEN, TO THE CONTRACT.
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STATE OF ILLINOIS |
} SS |
CONTRACTOR’S AFFIDAVIT |
COUNTY OF _____________________________ |
TO WHOM IT MAY CONCERN: |
|
|
THE UNDERSIGNED, (NAME) ____________________________________________ BEING DULY SWORN, DEPOSES
AND SAYS THAT HE OR SHE IS (POSITION) __________________________________________________________________ OF
(COMPANY NAME) _______________________________________________________________________________ WHO IS THE
CONTRACTOR FURNISHING __________________________________________________________ WORK ON THE BUILDING
LOCATED AT ________________________________________________________________________________________________
OWNED BY __________________________________________________________________________________________________
That the total amount of the contract including extras* is $______________________________ on which he or she has received
payment of $ __________________________ prior to this payment. That all waivers are true, correct and genuine and delivered
unconditionally and that there is no claim either legal or equitable to defeat the validity of said waivers. That the following are the names and addresses of all parties who have furnished material or labor, or both, for said work and all parties having contracts or sub contracts for specific portions of said work or for material entering into the construction thereof and the amount due or to become due to each, and that the items mentioned include all labor and material required to complete said work according to plans and specifications:
TOTAL LABOR AND MATERIAL INCLUDING EXTRAS* TO COMPLETE
That there are no other contacts for said work outstanding, and that there is nothing due or to become due to any person for material, labor or other work of any kind done or to be done upon or in connection with said work other than above stated.
DATE ___________________________ SIGNATURE _______________________________________________________
SUBSCRIBED AND SWORN TO BEFORE ME THIS _______________ DAY OF ___________________________,________,
*EXTRAS INCLUDE BUT ARE NOT LIMITED TO CHANGE
ORDERS, BOTH ORAL AND WRITTEN, TO THE CONTRACT.
________________________________________________
NOTARY PUBLIC
