On <lien date>, <Lienholder> caused a lien to be recorded against the property described as follows:
<Description of property.>
In consideration of <amount> Dollars, ($<0.00>), 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 < services performed by/materials provided by> by <Lienholder>, and does hereby authorize and direct that the above mentioned lien be discharged.
Signed 05 April, 2005,
STATE OF <State>, COUNTY OF <County>, ss.:
I, __________________________________, do hereby certify that on this
______ day of ________, __________, personally appeared before me
known to be the person(s) who executed the foregoing instrument.
Notary Public in and for the State of _________________.
My commission expires _______________.