STATUTORY FORM — Michigan

PARTIAL CONDITIONAL WAIVER

Michigan Construction Lien Act — MCL 570.1115(9)(b)

Project:	Sample Project
Property Description:	Sample Project — described in the contract
Owner:	Sample Project Owner LLC
Other Contracting Party:	Sample General Contractor LLC
Claimant:	Sample Subcontractor LLC
Claimant Address:	__________________
Claimant Phone:	__________________
Through Date:	June 30, 2026
Amount:	$50,000.00

I/we have a contract with Sample General Contractor LLC (other contracting party) to provide labor, services, equipment, and/or materials for the improvement to the property described as Sample Project — described in the contract, and by signing this waiver waive my/our construction lien to the amount of $50,000.00, for labor/materials provided through June 30, 2026 (date).

This waiver, together with all previous waivers, if any, (circle one) does / does not cover all amounts due to me/us for contract improvement provided through the date shown above. This waiver is conditioned on actual payment of the amount shown above.

The does / does not election above is made by the signer at the time of signing; neither option is preselected. The signed document records the signer's election.

If the improvement is provided to property that is a residential structure and if the owner or lessee of the property or the owner's or lessee's designee has received a notice of furnishing from me/one of us or if I/we are not required to provide one, and the owner, lessee, or designee has not received this waiver directly from me/one of us, the owner, lessee, or designee may not rely upon it without contacting me/one of us, either in writing, by telephone, or personally, to verify that it is authentic.

DO NOT SIGN BLANK OR INCOMPLETE FORMS. RETAIN A COPY.

Signature of lien claimant: ___________________________ Signed on: _______________ (date)

Printed Name of Authorized Signer: ___________________________

Title: ___________________________

Address: ___________________________

Telephone: ___________________________

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, MI, 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

Michigan lien waiver requirements

The Michigan statutory conditional progress waiver