SAMPLE
Not an executed instrument · specimen for demonstration only
Owner
Trustees of the University of Pennsylvania
General Contractor
Turner Construction Company
Project Name (the “Project” or “Premises”)
Penn Medicine Pavilion — Mechanical Fit-Out
Project Address
3400 Civic Center Boulevard, Philadelphia, PA 19104
Subcontractor
Keystone HVAC & Controls, LLC
Subcontractor Address
412 N 3rd Street, Philadelphia, PA 19123
Scope of Work
HVAC piping, equipment setting, and building-management controls for Levels 3–5, including air handlers AHU-3A/3B and associated hydronic specialties.
Requisition / Invoice #
APP-2026-07-014
Payment
$187,450.00
For Period Ending
July 31, 2026
Affidavit of Payments Made to Contractor / Subcontractor
As of August 21, 2026, the Subcontractor, whose address is 412 N 3rd Street, Philadelphia, PA 19123, in consideration of the sum of $187,450.00, does hereby waive and release his or her lien and right to claim a lien for labor, services or materials furnished through July 31, 2026, to Turner Construction Company (including Owner’s employees, agents, lenders, General Contractor, affiliates, or other designees) on the job of Penn Medicine Pavilion — Mechanical Fit-Out.
This Payment Certification and Waiver of Claims and Liens is conditioned upon the Subcontractor receiving collected funds in the amount of $187,450.00 for the work described herein.
The Subcontractor certifies that, upon receipt of the foregoing amount, certified by the Subcontractor and/or Architect/Engineer as due in connection with the application for a progress payment submitted with this Certification and Waiver of Claims and Liens, the Subcontractor: (a) has received payment in full for or on account of all amounts due under the subcontract or agreement for construction of certain Work on the Project referenced above through the end of the period covered by the application for payment, including any amounts due for extra or additional work, change orders, damages, delays, claims of any kind, or any other increase to the contract sum; and (b) waives, releases and forever discharges the General Contractor and the Owner from any and all obligations and liabilities arising under or on account of the subcontract or agreement and the Project, or either of them, through the end of the period covered by the application for payment, including any obligations or liabilities for extra or additional work, change orders, damages, delays, interest, penalties for late payment, attorneys’ fees, claims of any kind, or any other increase to the subcontract/contract sum, and hereby expressly waives and relinquishes the right to have, file or maintain any mechanic’s liens or claims against the Project, the building(s), the improvement, the land covered thereby and the lot or curtilage appurtenant thereto (the “Premises”), with the exception of additions, deletions or changes in the work directed by the Owner in accordance with the Contract Documents and/or the following specifically described claims for which written notice has been given to the General Contractor and the Owner on the date indicated: N/A.
The Subcontractor agrees and acknowledges that it may execute this Payment Certification and Waiver of Claims and Liens Form/Affidavit by electronic signature of a duly authorized officer of any party hereto, including, without limitation, “click through” acceptance, pursuant to electronic signature procedures as the parties may establish from time to time, shall be equally as effective as delivery of a manually executed or manually notarized copy of this document, and shall constitute a valid and binding execution and delivery of this document/agreement by the Subcontractor. Subcontractor agrees to notarize this document if requested at any future time by Owner. The Subcontractor further represents and warrants that s/he is duly authorized and empowered to sign and execute this Waiver and Release on their own behalf and on behalf of the company for which s/he is signing; that Subcontractor has properly performed all Work in accordance with any contract, all specified quality per plans and specifications and in a good and workmanlike manner; that Subcontractor has paid in full for all the labor, materials, equipment and services that they have used or supplied to the above Premises and that no other party has any claim or right of lien on account of Work performed or provided for the Subcontractor for Owner, Project or Premises, and that Subcontractor is in compliance with all relevant contracts and agreements related to the referenced project.
The Subcontractor certifies that all charges for labor, materials, services and every other nature in connection with the Subcontract for Work performed through the period covered by previous applications for payment have been paid in full, and that there remains no amount due, or claimed to be due, to any Subcontractor, vendor, or individual furnishing labor or material in connection with such Work, with the exception of the following: N/A. The Subcontractor hereby further declares and agrees that in the event that any lien or other claim should be brought against the General Contractor and/or the Owner, or the Project or Premises, the Subcontractor will protect the General Contractor and/or the Owner and defend any suit or action brought against the General Contractor and/or the Owner by reason of any lien or other form of claim or action arising out of the subcontract or agreement and hold the General Contractor and/or the Owner harmless and indemnified therefrom.
Sample · not an executed instrument · do not present to a lender
