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Final Waiver of Lien <br />(State of Indiana, County of l) �e SS; <br />being duly sworn that he/she is the I L4 � n 9 O. <br />(� (Name of Officer) (Title) <br />of having contracted with <br />(Contractor) (Owner) <br />to furnish certain materials and/or labor as follows; VAN).e� ' V'� t vv <br />(Description) <br />for a project known as Li <br />(Name ofProjeot) <br />located at Y-%Gv <br />and owned by C' -T `/ 0 r <br />(Owner) <br />and does hereby further state on the behalf afthe aforementioned subcontractor/supplier; <br />(PARTIAL WAIVER) that there is due from the Contractor the sum of <br />Dollars . <br />❑ receipt of which is hereby acknowledges]; or <br />❑ tits payment of which has been promised as the sole consideration for this Affidavit and Pined Waiver of Lien -which is given <br />solely with respect to said amount and which waiver sball be effectivo only upon receipt of payment thereof by the <br />undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor is the sure of <br />_($ ) <br />[� receipt ofwhiah is hereby acknowledged; or <br />❑ thepayment of which, has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shelf l <br />become effective only upon receipt of such payment. l <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 ormaterial or both, Iiu'nishe-d b the undersigned <br />theroto, subject to limitations or ooladitions expressed herein, if any, and ft'ther certified that no other party has any claim or right to a <br />lien on account of any work performed or material tumished to the un€dersi far said r at d wit in scope of this Affidavit j <br />and Waiver of Lien. <br />By <br />(Firm) (Authorized Representative) <br />STATE OF INDIANA ) <br />SS: <br />ST, JOSEPH COUNTY <br />136fore me, the undersigned, a Notary Public, In and for said County and State, personally appoared Ploy; V I�Y- <br />and acknowledged the execution of the :Foregoing Affidavit and Waiver of Liens. <br />W TNLSS 'WJfIMOF, Ihave hereunto subscribed my name and affixed my official seal on the �h day of <br />j <br />Notary Mile Signature <br />My Commission Expires; 0r <br />11 i <br />Residing in -, Jb S e-Cauuty, �n L4L ` et ►2E FgtitryPab � H REIF 3 <br />Notary Public, tale of Indiana <br />Saint Joseph County <br />sEnc : Commission to 639359 <br />My Commission Expires i <br />October 23, 2020 <br />