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WAIVER AND RELEASE OF LIENS
Period Through: (hereinafter Release Date)
Month / Day / Year
The undersigned is a general contractor, subcontractor, materialman or other person furnishing services or labor or material in the construction or repair of improvements upon real estate owned by:
And said real estate is described as follows:
In consideration of the sum of $10.00 to the undersigned in hand paid, receipt and sufficiency of which is hereby acknowledged, and other benefits accruing, the undersigned does hereby waive, release and quitclaim in favor of the owner or owners of said real estate and in favor of each and every party making a loan on said real estate, and his or its successors and assigns, all rights that the undersigned may have to a lien upon the above-described land and improvements thereon by reason of or on account of any work, labor, services, equipment and materials furnished by the undersigned whether fully described and identified herein or not through the Release Date.
Service / Work Rendered:
Original Contract Amount: $____________________________
Previous Payments: $____________________________
Current Payments: $____________________________
Contract Balance: $____________________________
Dated this day of , 20 .
Name of Subcontractor, Supplier, etc.
Signature Title
Address
Date signed Telephone
WARNING
IT IS A CRIMINAL OFFENSE TO SIGN THIS AFFIDAVIT IF THERE IS ANY SUM DUE OR CLAIMED TO BE DUE FOR LABOR OR MATERIAL AND NOT DISCLOSED HEREIN.
Form No. 514a (Rev. 5/2002)
Local Agent:
West Virginia Bankers Title, LLC
1547 Tulip Lane
Fairmont, WV 26554
Phone: (877) 439-4910
Fax: (877) 451-8826
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