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AFFIDAVIT AND WAIVER OF LIEN
<br />PROJECT NUMBER:
<br />State of INDIANA, County of ST. JOSEPH as:
<br />The undersigned, being first duly sworn, states, warrants and deposes, personally and as a duly authorized officer or
<br />representative of the Subcontractor as designated below (referred to herein as "Subcontractor') as follows:
<br />Desianation of Instrument
<br />This is a: []Partial (Affidavit & Waiver of Claims) ®Final (Affidavit & Waiver of Claims)
<br />And is: ®Conditional (Payment To Fallow) ā¯‘Unconditional (Payment Received)
<br />This Instrument Pertains To The Foilowino:
<br />Subcontractor Name: If
<br />Subcontractor Address:_
<br />Name of Person Signing:
<br />Project (Name): Fellow:
<br />Project Location/Address;
<br />Owner:
<br />Payable through the period ending (date): December 13, 2016
<br />The Timms of This Instrument Are:
<br />as the "Effective Date")
<br />1. Subcontractor has contracted with Contractor to furnish labor, materials, equipment and/or services in furtherance of Contractor's
<br />contractual obligations for the described project.
<br />2. If this Instrument Is designated as a Partial Affidavit and Waiver, the Payment Amount recited above is the current balance due the
<br />Subcontractor, and such amount, together with any and all previous payments received by Subcontractor, is the total sum due to
<br />Subcontractor, exclusive of contractually, provided retalnage, for all labor, materials, equipment or services furnished by or through
<br />Subcontractor to or for the Contractor In respect of the Project through the above stated Effective Date. If this Instrument Is designated
<br />a Final Affidavit and Waiver, the Payment Amount Is the full and final amount due the Subcontractor for any and all labor, materials,
<br />equipment or services furnished or to be furnished by or through the Subcontractor for the Project.
<br />3. The listing on the attached Application For Payment form Is incorporated herein by reference and sets forth, fully and correctly, the
<br />names of sub -subcontractors, materialmen, equipment lessors and laborers engaged by or under the employ of Subcontractor and to
<br />whom monies are presently due and owing from Subcontractor for labor, materials, equipment or services furnished to or for the Project.
<br />Except as otherwise specifically stated in such listing in sub -subcontractors, materialmen and laborers engaged or employed by
<br />Subcontractor have been paid in full for all labor, materials, equipment or services furnished in respect of the Project.
<br />4. In consideration of payment of the Payment Amount, the Subcontractor completely waives, discharges and releases the Contractor, any
<br />and all owners of any title or Interest in the real estate upon which the project Is situated, and their respective sureties, successors
<br />assigns, from all liens and claims whatsoever in respect of or arising from any and all labor, materials, equipment or services furnished
<br />by or through Subcontractor to or for the Project, including without limitation mechanics' lions and claims against any contract
<br />proceeds. If this Instrument Is designated as a Partial Affidavit and Waiver, the waiver, discharge and release provided by this paragraph
<br />shall apply only to labor, materials, equipment or services furnished on or before the Effective Date hereof. If this Instrument is
<br />designated as a Final Affidavit and Waiver, the waiver, discharge and. release provided by this paragraph shall notwithstanding the
<br />Effective Date of this Instrument.
<br />S. The undersigned and Subcontractor will Indemnity Contractor and hold it harmless again any loss, cost or expense, Including cost of
<br />bond premiums, litigation expenses and attorney fees, for and In respect of any breach of any covenant, representation or warranty
<br />contained herein or any lien or other claim asserted by any person In respect of labor, materials, equipment or services which are within
<br />the scope of this Instrument.
<br />6. If this Instrument is Conditional, the terms hereof shall become effective upon payment of the Payment Amount to Subcontractor, or at
<br />Contractor's option, jointly to Subcontractor and any persons identified and In respective amounts as slated on the attached Application
<br />For Payment form, which payment shall the sole consideration of this Affidavit and Waiver. If this Instrument is designated above as
<br />Unconditional, the undersigned and Subcontractor acknowledge receipt "a Payment Amount and agree that this instrument shall be
<br />effective In all respects as of the date hereof. I -
<br />Subcontractotts Signature:
<br />Subscribed and Sworn to be me this 13 day of December 2016.
<br />rY; '
<br />Notary Public Signature: ` 1.. My Qommission Expires: September 26, 2024
<br />Printed Name: MICA M. McKinley - Residing n: St. Joseph County
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