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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of I 1 l�Q �`� SS: // <br />'��� �Q ZTf GH��✓J being duly sworn that he/she is the '&4—1 e <br />(Name of Officer) / / n (Title) <br />of A fCA/�l/1%�y G.G having contracted with ieZ7 e <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: 1&2A%Lf 10'4AT"' o Mz9a Aas <br />n (Description) <br />for a project known as a( �%�lo ✓/�/%iIf—or" 'r- Atep myiC7 <br />located at <br />and owned by <br />(Name of Project) <br />4.9.Q.sDds ,000.47XO�1t1' T� fDyriH �ld�a/,D� 1, /� <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier: <br />(PARTIAL WAIVER) that there is due fi'om 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 />WAIVER) that the final balance due from the contractor is the slim of <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 />10 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 properly 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 ttlaxo other party has arty im or right to a <br />lien on account of an work performed or material furnished to the undersigned for said ro'e t, a d t t the sc e o this Affidavit <br />y P Y l Jp <br />and Waiver of Lien. ,1 % l <br />"IC `• qyv <br />(Firm) �arr�r�oF LINDA J GIa�te, <br />(Authorized Representative) <br />STATE OF INDIANA ) " • Notary Public. Stat <br />;.�ownv •, St. Joseph C <br />SS: "x: xc <br />Commission N <br />ST. JOSEPH COUNTY ). SEAS r My Commissio <br />��' .... •P �� <br />Before me, the undersigned, a N tat %fuUitL man ersonally appeared <br />and acknowledged the execution of the foregoing f ldavit and Waiver of Lien. <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the day of <br />Notary Public $ gnatm•e Z <br />My Commission Expires: l3� _ z o/� / <br />61, /1=��V y <br />(9 <br />Residing in f f, JQf E P11 County, T /%zMIA Notary Public Name <br />