Appendix H - 12P - Lien Waiver-Contractor.pdf
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- Attached to
- Wilkeson Pointe Improvements ITB State and local contract opportunity
- Solicitation number
- 2097974
- Issued by
- Erie County, New York
About this file
This is a Contractor's Receipt and Waiver of Lien form (DC-105g) used by the New York State Urban Development Corporation d/b/a Empire State Development (ESD). The document serves as an official certification that a contractor has received payment for work performed on an ESD project and waives their right to file any liens against the project property. The form requires details including the ESD Project Number, ESD Requisition Number, project name, owner information, payment requisition number, and cumulative payment amount received.
The form includes spaces for documenting the contractor's acknowledgment of payment receipt, the waiver of any future lien rights related to the work completed through the date of the previous requisition, and requires notarization. It must be signed by an authorized officer of the contracting company and includes fields for contractor identification, payment amounts, dates of agreements, and relevant project information. The document appears to be a standard form used for ESD construction projects to ensure clear documentation of payments received and release of lien rights.
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Text version
DC-105g (06/16)
ESD Project No.:
ESD Requisition No.:
CONTRACTOR’S RECEIPT AND WAIVER OF LIEN
State of New York )
) ss.:
County of )
(“Contractor”), in connection with the construction of a project of the New York State Urban Development Corporation d/b/a Empire State Development (“ESD”) known as (the “Project”) and the payment by (“Owner”) to Contractor of certain sums requisitioned by the Contractor pursuant to its Request for Payment No. dated , ,20, (the “Requisition”), DOES HEREBY CERTIFY AND ACKNOWLEDGE that it has received the cumulative amount of $ , representing all sums due and owing to it in accordance with its agreement with the Owner dated , ,20__, other than sums, if any, withheld by the Owner in accordance with such agreement and approved by the Owner and ESD, for work performed or materials supplied for the Project to the date of , ___ 20__, and DOES HEREBY FOREVER RELEASE AND WAIVE for itself, its successor and assigns any and all rights, claims and demands it has or may have against the Owner and ESD, including any and all rights which it has or may have pursuant to the New York Lien Law to file any lien or notice of lien against the Project or any property of the Owner on account of or deriving from labor performed or materials furnished for the Project to the date of the previously submitted requisition dated , 20__.
IN WITNESS WHEREOF, Contractor has caused this Receipt and Waiver to be duly executed and the seal of the Contractor to be affixed as of the date of the Requisition by the undersigned duly authorized officer.
Contractor:
Name: Title:
On the day of , 20 , before me, the subscriber personally appeared to me personally known, who being by me duly sworn, did depose and say that he/she resides at ____ that he/she is of the entity described in and which executed the foregoing instrument.
Notary Public
My commission expires:
File details come from the government source that posted it. Updated .