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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of } 5 F �l �c�_ SS: <br />L � Q V t t (rt is \ being duly sworn that he/she is the !S W n < t� <br />(Name ofOfficer) (Title) <br />of Tx Ct­norakc--- C- a having contracted with l L Y'l C,G 00 �k 6 C ^J e1 <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: <br />for a project known as <br />located at <br />and owned by <br />,(> <br />lI 1 S hawa IC �1 / A t/ - <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 />(F AL WAVER) that the final balance due from the contractor is the sum of <br />i I Se oe J ,lug Z , ($ ) �k' 19, coo 7 e 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 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 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, and within tfls ssDpeyf this Affidavit <br />and Waiver of Lien. <br />TV (r) ar le Ig Le- C' . By ( <br />(Firm) (Authorized Represen a ry _ <br />STATE OF INDIANA ) <br />) SS: <br />ST.JOSEPH COUNTY ) 7 <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared. <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 9Z� day of <br />11�� Notary Public %Oiarme <br />My Commission Expires: 612 7l/ 2 <br />Residing in S O S � County, -A Notary Public, Nam <br />