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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of C/khiq/ 4— SS: <br />Qr,4, (mr� ✓ being duly sworn that he/she is the 0 <br />(Nafne of Officer) (Title) <br />of Z)'4��i Em/.a�ra having contracted with �'� Y� %o�/t 6 c 1,✓ r <br />(Subcontractor/Supplier) <br />(Contractor) <br />to furnish certain materials and/or labor as follows: C!r cam.., e / .�'e,,, n, W I. r _i T -Z <br />for a project known as <br />(Name <br />located at <br />-C <br />s-' a%c <br />and owned by <br />/�/ao <br />_Lr74, 0Ic <br />�co_A <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier: <br />(PARTIAL WAIVER) that there is due from the Contractor the sum of <br />Dollars <br />❑ receipt of which is hereby acknowledged; or <br />the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which is given <br />solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the <br />undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor is t4e sum of <br />St o_c>-Wc j,4 cf <br />❑ receipt of which is hereby acknowledged; or <br />❑ the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shall <br />become effective only upon receipt of such payment. <br />THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all liens or claims whatsoever <br />on the above -described property and improvements thereon an account of labor or material or both, famished b the undersigned <br />thereto, subject to limitations or conditions expressed herein, if any; and further certified that no other party has any claim or right to a <br />lien on account of any work performed or material famished to the undersigned for said project, and within the scope of this Affidavit <br />and Waiver of Lien. /I <br />Dal (SO!?P-M ' By <br />(Firm) (Autho ' d Representative) <br />STATE OF INDIANA ) <br />L 1 ekor+ ) SS: <br />ST-d9SERH COUNTY ) <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared _Llod e C=Q r Pr I� <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the day of <br />20V !�A / <br />^-- I <br />Notary Public Signature <br />My Commission Expires: 4 - a 4 —0 b,4 \ / <br />Residing in l✓ 1144, ri— county, <br />� Vl GL{. P-LY�GL NotaryyPublic Name <br />