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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of S7 d% e, E SS: <br />T i - E 41 17 being duly sworn that he/she is the f ra%,u✓ <br />(Name of Officer) _ (Title) <br />C'r'/y `off S�eu�� ��ar/ <br />of T_ j� r�_�Q�% �,�1r having contracted with �� �j,� 406dh-s <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: e 1 Q 1 0) kaf a e iiv�' ;,4L,2D�i�S <br />(Description) <br />for a project known as q <br />(Name of Project) <br />Iocated at 17r,9 7 Y, 61C)-V LET If C412_1i LAJ -274f <br />and awned by OF J;M ZC/ <br />(Owner) <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 />(FINALWAIVER) that the final balance due from the contractor is the sum of <br />_ <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 ject, and within the scope of this Affidavit <br />and Waiver of Lien, <br />`I Ct) Lt� LlV 1z ��t1` ®7i A) C By ~ <br />(Firm) (Authorized 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 AT�qi cf CC/t'it/! <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the �l�( day of <br />Not lic Sign <br />My Commission Expires: <br />_ ---� <br />Residing in7�LIO;j''`County, <br />— 1) Notary Public Name <br />