On [lien date], [Lien holder name] caused a lien to be documented against the property mentioned below:
-[Property Description] –
In consideration of $[amount], receipt of which is acknowledged, [Lien holder name] sets free the above-mentioned property and its possessor, [owner name], from any and all responsibility occurring from [services performed by/supplies provided by] by [Lien holder name]>, and does hereby approves and expresses that the above-mentioned lien be released.
[Lien holder sign]
State of [state name], County of [County name]:
I, __________________________________, do hereby confirm that on this
______ day of ________, __________, appeared before me personally
known to be the person(s) who executed the foregoing instrument.
Notary Public in and for the State of _________________.
My commission expires _______________.