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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of 1 � PQ r 1(V SS: <br />being duly sworn that he/she is the ly=t-3.�ti (Name of Officer) <br />n p A (Title) <br />of /J \II /J 11_. having contracted with <br />(Subcontractor/Supplier) (Contractor)S `al' /� J <br />to furnish certain materials and/or labor as follows: <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 Ikerl is ue from the Contractor the sum of AJ1p1 <br />t Dollars ki j A— <br />❑ receipt of which is hereby acknowledged; or <br />❑ the payment of which has been promised as the sole consideration for this Affidavit and I'inal 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�fipall balance due from the contractor is the sum of <br />!!VV (s ) A)A <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, furnished b the undersigned <br />thereto, subject to limitations or conditions expressed herein, if any; and further certified that no otter 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, a+ wi <br />and Waiver of Lien. thin the scope of this Affidavit <br />CA 011114 JAM By I -� <br />(F) STATE OF INDIANA (Authorized Representative) <br />) <br />LFlPo ) SS: <br />EP C <br />EPx COUNTY ) <br />Before me, the undersigned, a Notary Public, in and for said County and State, personal ehd <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WI S WHEREOF, I have hereunto subscribed my�n]am�e and �affixed official seal o the 3o day of <br />(D V Q.� P <br />F6 JW Signat <br />My Commtsslon Expires: 9!�' 2 A a% <br />(�, ,, a <br />ry:� ` _er � County, ; l t zt.a l_o`t; <br />ZA <br />Residi m t�:�.tacuu,r; <br />..Gag"t ' ' ; cxpiras No ie Name <br />Feislarp 3, i� 17 <br />