INTERIM WAIVER AND RELEASE OF LIENS AND CLAIMS UPON PAYMENT
STATE OF __________________ COUNTY OF ________________ The undersigned, ________________________________________________, (“Contractor”) has been engaged under agreement with Dimension One Inc., (“Builder”) to furnish certain materials, equipment, services, and/or labor for the project known as _______________________________________, (“Project”) which is located at ____________________________________________________ in the County of ______________________, (“Property”) and more particularly described as follows: Exhibit "A" Attached Upon receipt of the sum of $________________________, Contractor waives and releases any and all stop notices, liens or claims of liens and all claims, demands, actions, causes of action or other rights against Builder and upon the foregoing described Project and Property through the date of ____________________, 20___ (“Current Date”) and reserving those rights and liens that Contractor might have in any retained amounts, on account of materials, equipment, services and/or labor furnished by the undersigned to or on account of Builder for said Project. Contractor further represents that all employees, laborers, materialmen, subcontractors and subconsultants employed by Contractor in connection with the Project and all bills incurred through the Current Date for materials, equipment, services and/or labor, and taxes furnished by such parties to Contractor in connection with Contractor’s work on the Project have been fully paid and that no obligations, legal, equitable or otherwise, are, or shall be then, owed by Contractor to such parties. This Waiver and Release is freely and voluntarily given and the undersigned acknowledges and represents that it has fully reviewed the terms and conditions of this Waiver and Release, that it is fully informed with respect to the legal effect of this Waiver and Release, and that it has voluntarily chosen to accept the terms and conditions of this Waiver and Release in return for the payment recited above. The undersigned understands that the failure to complete correctly or fully any of the blank spaces in this document shall not invalidate the document so long as the subject matter of this Waiver and Release may reasonably be determined. FOR CONTRACTOR: Applicable to Payment Request(s) No. (or) Invoice(s) No. Date: Signed: _________________________________ (SEAL) By: __________________________________________ Title: ________________________________________
AFFIDAVIT On this day of , 20 , before me appeared the above-signed, known or identified to me personally, who, being first duly sworn, did say that s/he is the authorized representative of the above-referenced Contractor and that this document was signed under oath personally and on behalf of Contractor, by Contractor’s authority, and the above-signed acknowledged that this Affidavit was executed as a free act and deed of Contractor and that, under oath and from personal knowledge, all contents of this Interim Waiver and Release are true and correct.
___________________________________, Notary Public