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AFFIDAVIT AND WAIVER OF LIEN <br />Star of Indiana, County of ter— SS. bJg J <br />duly sworn that he/she is the �r CS 1 <br />(Name of Offirfeli (Title) <br />of S ( 6 Q Rz"=-4ni having contracted with <br />(Subcontractor/Supplier) ' 1 n (Contractor) <br />to furnish certain materials and/or labor as follows: U�� �"rt„,-� <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 there is due from the Contractor the sum of <br />Dollars ($ ) <br />❑ receipt of which is hereby acknowledged; or <br />211� 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 />FINAL WAIV that the fipal/jfahan�ceco®{racto isyt/h�esum of I )� <br />/L.l w .1t tip+ J/`iv'r <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 F,*99#nt of labor or material or both, furnished b the undersigned <br />thereto, subject to limitations or conditions expressed he�ef41+,jt�ny�d, er certified that no other party has any claim or right to a <br />lien on account of any work performed or material furlusQ-to the under4ed for said project, and within the scope of this Affidavit <br />and Waiver of Lien. <br />(Firm) eb q ,t 7Authorfz <br />e tepresentahve) <br />STATE OF INDIANA ) �� <br />SS. <br />ST. JOSEPH COUNTY %� ) <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared h�'-24 CdJ Ley o� <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />INTNESS WHEREOF, I have hereunto subscribed r an off . 1 dal on the _ �� day of <br />Lou Ann Ward No ry Public Signature <br />Notary Public for the Stat of IW <br />My Commission Expires: Countv of esklenoe- E k ✓ 1. <br />Expires 9/1/2021 <br />Residing in County, Notary Public Name <br />