GA Interim Waiver and Release Upon Payment

Exhibit A

Interim Waiver and Release Upon Payment

STATE OF GEORGIA

COUNTY OF________

The undersigned mechanic and/or materialman has been employed by _______________ (name of contractor) to furnish _______________________(describe materials and/or labor) for the construction of improvements known as __________________ (title of the property or building) which is located in the City of _________, County of _____________, and is owned by _______________ (name of owner) and more particularly described as follows:
________________________________________________________________________________________________________________________
(DESCRIBE THE PROPERTY UPON WHICH THE IMPROVEMENTS WERE MADE BY USING EITHER A METES AND BOUNDS DESCRIPTION, THE LAND LOT DISTRICT, BLOCK AND LOT NUMBER, OR STREET ADDRESS OF THE PROJECT.)

Upon receipt of the sum of $__________, the mechanic and/or materialman waives and releases any and all liens or claims of liens it has upon the foregoing described property or any rights against any labor and or material bond through the date of _________(date) and excepting those rights and liens that the mechanic and/or materialman might have in any retained amounts, on account of labor or materials, or both, furnished by the undersigned to or on account of said contractor for said building or premises.

Given under hand and seal this ____ day of __________, _____.

__________________________________(seal)

Signed, sealed and delivered in the presence of:

__________________________________
Unofficial Witness

___________________________________
Notary Public

My Commission expires: ______________

NOTICE: WHEN YOU EXECUTE AND SUBMIT THIS DOCUMENT, YOU SHALL BE CONCLUSIVELY DEEMED TO HAVE BEEN PAID IN FULL THE AMOUNT STATED ABOVE, EVEN IF YOU HAVE NOT ACTUALLY RECEIVED SUCH PAYMENT, 60 DAYS AFTER THE DATE STATED ABOVE UNLESS YOU FILE EITHER AN AFFIDAVIT OF NONPAYMENT OR A CLAIM OF LIEN PRIOR TO THE EXPIRATION OF SUCH 60 DAY PERIOD.  THE FAILURE TO INCLUDE THIS NOTICE LANGUAGE ON THE FACE OF THE FORM SHALL RENDER THIS FORM UNENFORCEABLE AND INVALID AS A WAIVER AND RELEASE UNDER O.C.G.A. SECTION 44-14-366.