STATUTORY FORM — Georgia

WAIVER AND RELEASE OF LIEN AND PAYMENT BOND RIGHTS UPON INTERIM PAYMENT

Georgia O.C.G.A. §44-14-366

STATE OF GEORGIA
COUNTY OF __________________

The undersigned mechanic and/or materialman has been employed by Sample General Contractor LLC (name of contractor) to furnish labor, services, equipment, and/or materials for the construction of improvements known as Sample Project (title of the project or building) which is located in the City of Anytown, County of Sample County, and is owned by Sample Project Owner LLC (name of owner) and more particularly described as follows:

Sample Project — described in the contract

Upon the receipt of the sum of $50,000.00, 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 June 30, 2026 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 __________________, 20_____.

Sample Subcontractor LLC
(Name of mechanic and/or materialman)

Signature of Claimant: ___________________________ (SEAL) Date: _______________

Printed Name of Authorized Signer: ___________________________

Title: ___________________________

Witness: ___________________________ (WITNESS)

Witness Address: ___________________________ (ADDRESS)

NOTICE: WHEN YOU EXECUTE AND SUBMIT THIS DOCUMENT, YOU SHALL BE CONCLUSIVELY DEEMED TO HAVE WAIVED AND RELEASED ANY AND ALL LIENS AND CLAIMS OF LIENS UPON THE FOREGOING DESCRIBED PROPERTY AND ANY RIGHTS REGARDING ANY LABOR OR MATERIAL BOND REGARDING THE SAID PROPERTY TO THE EXTENT (AND ONLY TO THE EXTENT) SET FORTH ABOVE, EVEN IF YOU HAVE NOT ACTUALLY RECEIVED SUCH PAYMENT, 90 DAYS AFTER THE DATE STATED ABOVE UNLESS YOU FILE AN AFFIDAVIT OF NONPAYMENT PRIOR TO THE EXPIRATION OF SUCH 90 DAY PERIOD. THE FAILURE TO INCLUDE THIS NOTICE LANGUAGE ON THE FORM SHALL RENDER THE FORM UNENFORCEABLE AND INVALID AS A WAIVER AND RELEASE UNDER O.C.G.A. § 44-14-366.

Administrative Reference Certificate

Review before relying on this waiver: These reference fields are generated from customer-provided and connected system data. They are provided to help identify the project, contract, PO, invoice, payment application, amount, payment period, and payment-status attestation. If any field is inaccurate or incomplete, do not sign or rely on this waiver; contact the sender for correction. This certificate is not legal advice and is not part of any statutory lien waiver form body.

Project:	Sample Project
Project Location:	123 Jobsite Rd, Anytown, GA, 00000
Project County:	Sample County
Property Description:	Sample Project — described in the contract
Owner:	Sample Project Owner LLC
Claimant / Subcontractor:	Sample Subcontractor LLC
Customer / Contractor:	Sample General Contractor LLC
Contract / PO Number:	PO-0000
Contract / PO Title:	Sample Scope
Invoice Number:	INV-0000
Payment Application Number:	PA-01
Payment Period:	Sample period
Through Date:	June 30, 2026
Payment Amount:	$50,000.00

Georgia lien waiver requirements

The Georgia statutory conditional progress waiver