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u <br />State of Indiana. County of <br />Jeff Bucher, Jr. <br />ISA Form # 1-402 <br />AFFIDAVIT AND WAIVER OF LIEN <br />Final 0 Partial V' Payment to Follow, <br />St. Joseph , SS: <br />IName of Officer) <br />Edward J. White, Inc. <br />{Subcontractor: Supplier) <br />materials and/or labor as follows: <br />PREPARE IN DUPLICATE <br />original - Contractor <br />Duplicate - Subcontractor/Supplier <br />being duly sworn states that he is the Vice -President of <br />[Tatel <br />having contracted with64ner•, °- AFL', I,, LJ-,-Is _ to furnish certain <br />(Contractor) <br />mechanical material and labor <br />j'Pescriplio ) <br />for a project known as m.,c ,4*..Ci �vl•^� <br />U— — <br />located at tuo !.us >7 SL Scu"Pvrrof Li and owned by Cr �,,, n�► �Je�v�. ���� <br />(Owner) <br />and does hereby further state on behalf of the aforementioned subcontractorisupplier: . <br />(PARTIAL WAIVER) that there is due from the contractor the sum of <br />Dollars ($ <br />[ 1 reoelpt of which is hereby acknowledged; or <br />[ 1 the payment of which has been promised as the sole consideration of this Affidavit and Partial Waiver of <br />Lien which is given solely with respect to said amount, and which waiver shall be effective only upon receipt <br />of payment thereof by the undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor is the sum of <br />77f1L�z; eu5�,�p AjJn " oo Dollars (S �� 000 .00 <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 <br />Lien which shall become effective upon receipt of such payment. <br />THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all lien or claim whatsoever <br />on the above -described property and improvements thereon on account of LABOR or material or both, furnished by the <br />undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certifies that no other party <br />has any claim or right to a lien on account of any work performed or material furnished to the undersigned for said project, <br />and within the scope of this affidavit and waiver. <br />Edward J. White, Inc. <br />1 Firml <br />WITNESS MY HAND AND NOTARIAL SEAL, this <br />My Commission Expires: August 10, 2UZ2 <br />By 1 Title <br />ulKortzed 11, <br />esenlative) <br />Residing in _ St. Joseph County <br />0 1979 INOIANA SUBCONTRACTORS ASSOCIATION. INCORPORATED <br />Unauthorized Reproducuan Proh,biled <br />Vice -President <br />Z 3 r day of20 ! g <br />` INotaf ubilcl <br />. Prt d: &6hael E. Taylor <br />`� { • .x°`} Rev. 10182 <br />