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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of � r , } <br />tt S S: <br />�Cocp.6Th being duly leer sworn that is the <br />r �)4 IfrlLticr <br />of I A (title) <br />(Subcontractor/Supplier) having contracted with Lxekk lolykcqlaca <br />(Contractor) �')�� <br />to furnish certain materials and/or labor as follows: <br />-- ---- <br />for a project known as <br />located at <br />and owned by <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier: <br />(PARTIAL WAIVER) that er IsAJue from the Contractor the sum of <br />Dollars 1 <br />❑ receipt of which is hereby acknowledged; or <br />❑ the payment of which has been promised as the sole consideration for this Affidavit and F nal Waiver of Lien which is given <br />solely with respect to said amount, and which waiver shall be effective undersigned; only upon receipt of payment thereof by the <br />(FINAL WAIVER) that thefitpal balance due from the contractor is the sum of <br />N <br />❑ receipt of which is hereby acknowledged; or <br />❑ the payment of which has been promised as the sole consideration for this Affidavit and Fiial 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 .md all liens or claims whatsoever <br />on the above -described property and improvements thereon an account of labor or material or both, furnished 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 furnished to the undersigned for said project, am within the scope of this Affidavit <br />and Waiver of Lien. <br />lm By lXS1XJln_ <br />STATE OF INDIANA ) (Authortzad Representative) <br />cW-fh;R IE ) SS: <br />�H COUNTY ) <br />Before me, the undersigned, a Notary public, in and for said County and State, ersonall <br />and acknowledged the execution of tine foregoing Affidavit and Waiver of Lien. p ed�h�_ <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed m fficial seal on e <br />fit]✓P111 �o Q �•� 3O day of <br />N ary c tgnature <br />My Commission Expires:� " �i -�O 1'%`'`�'-;�w;=�-r,-�...,<^._:� _- <br />_ y; w�a <br />Residing in L1p e iM1 <br />IB T <br />