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State of Indiana, County of <br />t <br />�\Jmto -&MO)n being duly sworn that he/she is the otuq a , <br />(Name of Officer) (Title) <br />M <br />(Subcontractor/Supplier) <br />to famish certain materials and/or labor as follows: <br />for a project known as <br />located at <br />and owned by <br />having contracted with a <br />A n <br />Y& UC <br />(Contractor) <br />ff ()escription) <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 />0 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 />WAIVER) that the fitlal ba,lance 4ue from the contractor is the sum of <br />El 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 project, and within the scope of this Affidavit <br />and Waiver of Lien. <br />CARW_ M. MOORE <br />(Firm) Notary Public - State at Indiana-- <br />Qr- I <br />SS: <br />Representative) <br />I <br />STATE E UP INDIANA Commission Number: 682645 <br />) SS: My Commission Expires May 6,2024 <br />ST, JOSEPH COUNTY <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared <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 any official seal on the <br />"' Inn , <br />Notary Public Signature <br />My Commission Expires: <br />Residing in 51 County, V, <br />__r- _p,j a 6 Notary Public Name <br />/ 0 4 day of <br />