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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of <br />(Name jof 0111cer) being duly sworn that he/she is the )1 i� � / y f"qN (_ <br />of I (Trt)�e) tL,C 1 <br />(Subcontractor/Supplier) having contracted with41 <br />to famish certain materials and/or labor as follows: <br />for a project known as <br />located at <br />and owned by <br />(Contractor) <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier: <br />(PARTIAL WAIVER) that terg is� ue from the Contractor the sum of <br />/� <br />Dollars (S <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 undersigned; only upon receipt ofpayment thereof by the <br />(FINAL WAIVER) that th7fi al balance due from the contractor is the sum of <br />A <br />❑ receipt of which is hereby acknowledged; or <br />i <br />❑ the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shah <br />become effective only upon receipt of such payment <br />I <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, furnished b the undersigned <br />thereto, subject to limitations or conditions expressed herein, if an ; and further certified that no other <br />lien on account of any work performed or material furnished to the undersigned for said project, d withhin the sany claim or right to a <br />cope off this Affidavit <br />it <br />and Waiver of Lien. <br />(Firm) BY )�(nA :/1 U�d �^ pn /'lI/)4/7V <br />St T�� OF I DIANA ) (Author ed Representative) <br />, .10b HCOUNTY ) SS: <br />Before me, the undersigned, a Notary Public, in and for said County and S <br />and acknowledged the execution of the foregoing Affidavittate, personally appeared and Waiver of Lien. <br />IIN�W;IT�.NE S WHEREOF, I have hereunto subscribed name and affixed in vial se!l on theme y f <br />/ day o <br />Niy Commission Expires: _�1— <br />�i / I Residingin L.,XArr— County, viy ��rnrd �'x+iras �U <br />Ituowrtame <br />