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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of Sr 750 s2Pl+ `SS': n <br />OA\N o L j i- 0 �R being duly sworn that he/she is tile �/e I L-t <br />(Name of Officer) (Title) <br />of U!-: S LvOt having contracted with J)4-:�L /5Z VI Lrt5S r L <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: <br />for a project known as 1 crt i m-u �T 12A� � —?_ 0 o <br />(Name of Project) <br />located at <br />and owned by L tT <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 />(FINAL WAIVER) that the final balance due from the contractor is the sum 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 />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 parry 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 the scope of this Affidavit <br />and Waiver of Lien. <br />p(3L V_KiJ =_3 IW L ByDas. <br />(Firm) (Authoriied Representative) <br />STATE QFINDL BIA ? I" ) <br />mart • f\ ) SS: <br />-STr393E7H COUNTY ) 1 <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appearedfn�I� <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITN ESS WFIEI,iEOF, I have hereunto subscribed my name and affixed my official seal on the � 4 ^ day of <br />,/i1 `-,/&_2Comn*FF92M4 <br />FRANK C. LAW SON 204 kf <br />NOTARY PUBLIC Ndt ub is Signature <br />STATE OF FLORIDA <br />My Commission Expires: <br />Expires \ r "r �1�. c , L� �s, <br />Residing in �� County, V 1 -\� r 1 rl \N Notary Public Name <br />