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AFFIDAVIT'' AND WAIVER OF LIEN <br />State of Indiana, County of <br />MM <br />1,44 se- 1 114 al� I ' - being duly sworn that he/she is the <br />(Name of Officer) (Title) <br />of T. f- M ( ft ',",a 'r Ate- having contracted with &14 411,(*- �VV'lggr (,, 7e'l if <br />(Subcontractor/S6pplier) (Contractor) " o 1,4 do 14 <br />to furnish certain materials and/or labor as follows: <br />for a project known as <br />located at <br />and owned by <br />(Description) <br />0 Fe 04 <br />(Name of Project) <br />(Owner) <br />and does hereby finther 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 />F-1 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 />4 receipt of which is hereby acknowledged; or <br />El 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 laborormaterial 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 />r <br />&C14' 2,41c, <br />(Firm)/ <br />13Y <br />(Authorized Replesentative) <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 <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 <br />200 <br />Notary Public Signature <br />My Commission Expires: <br />day of <br />Residing in County, Notary Public Name <br />