CONDITIONAL WAIVER AND RELEASE ON PROGRESS PAYMENT
Pursuant to California Civil Code § 8132 • Mandatory Statutory Wording
NOTICE: THIS DOCUMENT WAIVES THE CLAIMANT'S LIEN, STOP PAYMENT NOTICE, AND PAYMENT BOND RIGHTS EFFECTIVE ON RECEIPT OF PAYMENT. A PERSON SHOULD NOT RELY ON THIS DOCUMENT UNLESS SATISFIED THAT THE CLAIMANT HAS RECEIVED PAYMENT.
IDENTIFYING PROJECT & PAYMENT INFORMATION
EXCEPTIONS (THIS DOCUMENT DOES NOT AFFECT ANY OF THE FOLLOWING):
(1) Retentions retained before or after the Through Date; (2) Extras for which the claimant has not received payment; (3) Disputed claims in the following specific amounts:
✍️ CLAIMANT SIGNATURE (Draw with Mouse/Finger or Type Below)
Jordan Vance
Or Type Cursive Signature:
STATUTORY NOTARY PUBLIC ACKNOWLEDGMENT
State of •
County of
This instrument was acknowledged, subscribed, and sworn to before me on this
day of
,
by Jordan Vance, on behalf of Claimant.
Notary Public Signature: ____________________________________My Commission Expires: _______________ [NOTARY SEAL]
💵 IRS & FLSA Compliant Earnings Statement: Enter Regular & Overtime (1.5×) hours below. Social Security (6.2%), Medicare (1.45%), and Federal/State withholding calculate automatically or can be overridden inline.
EARNINGS STATEMENT / PAY STUB
Period Start
Period End
Pay Date
Employee Name & Role
Employee ID & SSN (Last 4)
W-4 Filing Status
Check / Direct Deposit Advice #
Earnings Type
Hours
Rate ($)
Current ($)
YTD ($)
Regular Hourly Pay
$2,720.00
$16,320.00
FLSA Overtime (1.5×)
$306.00
$1,836.00
Bonus / Commission
—
—
$900.00
GROSS EARNINGS
$3,176.00
$19,056.00
Statutory Taxes & Deductions
Current ($)
YTD ($)
Federal Income Tax (IRS W-4)
$1,874.40
Social Security (FICA 6.2%)
$1,181.47
Medicare Tax (FICA 1.45%)
$276.31
State Income Tax Withholding
$809.88
Pre-Tax Medical / 401(k)
$570.00
TOTAL TAXES & DEDUCTIONS
$785.34
$4,712.06
🏦 DIRECT DEPOSIT & NET PAY ADVICE VOUCHER (NON-NEGOTIABLE)
Pay To The Order Of: David Miller