Appendix J - 13P - Lien Waiver-Subcontractor.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 document is a Subcontractor's Receipt and Waiver of Lien form (DC-105h) used by the New York State Urban Development Corporation d/b/a Empire State Development (ESD) for construction projects. The form serves as an official certification that a subcontractor has received payment for work performed and materials supplied up to a specific date, and waives their right to file any liens against the project or owner's property for work completed through the date of the previously submitted requisition.
The document requires specific details including the ESD Project Number, ESD Requisition Number, cumulative payment amount received, agreement date with the contractor, and project completion dates. It must be executed in the presence of a notary public and includes spaces for contractor name, title, and authorized signatures. This legal instrument protects ESD and the property owner from future lien claims while documenting proper payment to subcontractors for completed work.
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Text version
DC-105h (06/16)
ESD Project No.:
ESD Requisition No.:
SUBCONTRACTOR’S RECEIPT AND WAIVER OF LIEN
State of New York ) ) ss.:
County of )
(“Subcontractor”), 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 to the Subcontractor by (the “Contractor”) of certain sums requisitioned by the Contractor pursuant to the Contractor’s Request for Payment No. dated , , 20 submitted to (“Owner”), (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 Contractor dated , 20 , other than sums, if any, withheld by the Contractor 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, Subcontractor has caused this Receipt and Waiver to be duly executed and the seal of Subcontractor to be affixed as of the date of the Requisition by the undersigned duly authorized officer.
Contractor:
Name: Title:
On this 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:
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