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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of SS: <br />rr�� , <br />��e_ L u c j�_V:l� [ # t A Gt _ being duly sworn that he/she is the 0 w Y� c r' <br />(Name of Offkdr) (Title) <br />Of }laving contracted with ' ��� �� �r r� ' <br />(Subcontractor/Supplier)� - t) 0 ` <br />(Contractor) <br />to furulsh certain materials and/or labor as follows: Cc-) � G 1": e <br />for a project known as <br />located at <br />and owned by <br />(Owner) <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier: <br />(PARTIAL WAIVER) that there is due &•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 />(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 bout, 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 sal project, and within th!2_wo is Affidavit <br />and Waiver of Lien. <br />BY r � <br />(Firm) By <br />Representative) <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 L Y�.tT JAJDA <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien, t.""' <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the � ay of <br />4 <br />Notary Public Signature <br />My Commission Expires: j S gw-o <br />Residingin 'r >JR �N %t.7r,x'ucF� <br />S 3aSP County, Notary Public Name <br />AARON MISTR011TRIILM <br />Notary Public, State of fnd[ana <br />St. Joseph County <br />My Commiss3on fxptres <br />October 15, 28Zt) <br />