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On [date]   , [name of lienholder], of   [address] ,

City of           , State of            , entered into an agreement with
[name of person], of   [address]    ,

City , of                , State of          

to [subject of lien]

at the property of [property owner] , of  [address] ,

which property is described as follows:

On [date]  , [lienholder] , caused a lien

to be recorded against the property described herein in the office of

           , of the County of           , State of          .

Said lien was duly recorded in Volume    , page  , of     .

In consideration of [amount]               Dollars, ($       ),

receipt of which is hereby acknowledged, [lienholder]

releases the above described property and its

owner, [name of owner]   from any and all liability

arising from the services performed by [lienholder]

under the terms terms and conditions of the herein referenced contract,

and does hereby authorize and direct that the above mentioned

lien be discharged of record.

Dated:_________________             ________________________