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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of S t , s , 5-R'y SS: <br />cJ 1 e— :� t-e-.\k,5 being duly sworn that he/she is the i fkl e-5 `kl <br />(Name of Officer) (Title) <br />of CAS having contracted with C S UAL t�'� 0-1 ?.�?ems �'%Tie.vL tC . <br />(Subcontractor/Su plier) (Contractdrr)f <br />to furnish certain materials and/or labor as follows: 2 b `k `(_L�_ S kcA K) S <br />for a project known as 2 0 �� �� 44�� CoC.y~,&O Re- •4 . +`S <br />(Name of Project) <br />located at <br />and owned by C. t j cam- -D A-4 -... <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 />RIVER) that the final balance due from the contractor is the sum of <br />❑ receipt of which is hereby acknowledged; or <br />NI the payment of which has been promised as the sole consideration for this Aff davit 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 fin they certified that no other party has any claim or right to a <br />Hen 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. n <br />VA+5 6,J —t 04- kN—( u-c- By _Atcz� <br />(Finn) (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 -5-r�e <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN E S �OF,have hereunto subscribed my name and affixed my official se on the / day of-T,.,L�/ <br />_96- 201 2 l I <br />Notary Public Signature <br />My Commission Expires: HA L, 11�0'JJf 4 <br />f NotaryPublic, State of Ind n l ls' / ` ✓ �� <br />Residing in �1 h County f �� r.ty of St!c�srp7 Notary Public Name <br />F,l Hf—ni5simi 4,41846 <br />Commission kxpires June 29, 2021 <br />