Original Contract Amount: $_________________
Previous Payments: $_________________
Current Payments: $_________________
Contract Balance: $_________________
STATE OF VIRGINIA _______________________
COUNTY OF FAIRFAX ______________________ ; To wit:
KNOW ALL MEN THAT ___________________________________________, for and in consideration of, the sum of _____________________________________, in payment of invoice or application dated _____________________________, does hereby waive, release and relinquish any and all claims of lien which ______________ now has upon the premises known and described as __________________________, ___________________________________________________________________ for labor, materials and services furnished prior to _____________________________________________________________________ said premises being owned by ____________________________________________ ____________________________________________________________________.
Subscribed and sworn to before me this _____ day of ____________, 20_____.
My Commission Expires: _________________
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