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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of SSA <br />being duly sworn that he/she is the <br />;?Name of Officer) f it <br />(Title) <br />of 44- having contracted with <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows. <br />for a project known as rflou"i(- <br />located at <br />and owned by <br />(Owner) <br />(Description) <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 />M receipt of which is hereby acknowledged; or <br />M <br />El 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 fin balance due fro the contractor is the a <br />ke 'o <br />A'C �t 1, <br />StlqL 'a ya <br />85 <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 party has any claim or right to a <br />lien on account of any work performed or material furnished to the undersigned for said prject, and ithin the scop <br />and Waiver of Lien. Z-) of this Affidavit <br />-W Zaw 'WI V Vr W �'v � �w <br />0"W'w <br />(Finn) <br />PATRICIA A 'BOWERS (A4thotizerepres'enfati Notary <br />Slate of IndanC' <br />STATE OF INDIANA ry Public Sea] State of Indiano <br />M ary "'0 "a <br />SS: ELK�HART County <br />ST. JOSEPH COUNTY My Commission Expires 04/2412024 <br />Commission <br />iC <br />W L . MV U v <br />Before me, the undersigned, a Notary ub 'c, in an or said County and State, personally appeared K, eiq*5f <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. I g <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the day of <br />Eaefillb C-C 20X 11, <br />Notary Public Signature <br />My Commission Expires: L-po-�? o <br />Residing in ELK116e7- county,_ Not Public Name <br />