RECEIPT AND WAIVER OF MECHANIC'S LIEN RIGHTS Minnesota Uniform Conveyancing Blanks Form 40.5.1 (2011) DATE: (month/day/year) The undersigned hereby acknowledges receipt of the sum of $ as Check only one box or box 1 will apply. 1. partial payment for labor, skill, and material furnished 2. payment for all labor, skill, and material furnished or to be furnished (except the sum of $ retainage or holdback) 3. full and final payment for all labor, skill, and material furnished or to be furnished to the following described real property: For value received the undersigned waives all rights acquired by the undersigned to record a mechanic's lien against said real property for labor, skill, or material furnished to said real property (only for the amount paid if Box 1 is checked, and except for retainage shown if Box 2 is checked). The undersigned affirms that all material furnished by the undersigned has been paid for, and all subcontractors retained by the undersigned have been paid in full, EXCEPT: (print name) By: (signature) Its: (type of authority) Address: Phone Number: Note: This form is not intended to be recorded. Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com