Customer Name Customer Address
Customer City/State/Zip Customer Phone Number
Job Location Date
Contractor Address ________________________________________________
Description of work completed to date: ________________________________
Payments received to date: $___________
Payment received on this date: $_________
The Contractor signing below acknowledges receipt of all payments stated above. These payments are in compliance with the written contract between the parties above. The Contractor signing below hereby states payment for all work done to this date has been paid in full.
The Contractor signing below releases and relinquishes any and all rights available to place a mechanics or material man lien against the subject property for the above described work. All parties agree that all work performed to date has been paid for in full and in compliance with their written agreement.
The undersigned Contractor releases the Customer for any liability from non-payment of material or services extended through this date. The undersigned contractor has read this entire agreement and understands the agreement.
Given under hand and seal this _____day of __________________, 20___.
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