Laserfiche WebLink
AFFIDAVIT AND WAIVER OF LIEN <br />� I I h"t Vh <br />State of Indiana, County of A" SS: <br />LRK, ouivkctik - <br />(Name of OfMer) <br />being duly sworn that he/she is the <br />of bilk, having contracted with <br />(Subcontractor/Supplier) <br />to furnish certain materials and/or labor as follows: <br />for a project known as <br />located at <br />ME <br />(Title) <br />001) Nhl (C h[Loyks <br />(0fitractor) <br />WAY It (10Y)NIO-A-C <br />(Description) <br />VOW- no <br />(Name of Project) <br />and owned by 'A,A (I IAJJA , V (Owner) <br />and does hereby farther 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 />0 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 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 />6�t <br />WAIVER at the final balance due from the contr t )r is the u of S( ( TAT <br />Elc <br />in twt�A+j fvw- 140 <br />E-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 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, famished 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 �thesco e of this Affidavit <br />and Waiver of Lien. <br />By <br />(Firm) <br />STATE OF INDIANA (Authorized Representative) <br />SS: <br />ST. JOSEPH COUNTY <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared -I)s r— Z A-6 <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 s ado lve day of <br />vic 'TORIA V, SMITH ota u 9 tare <br />NO WAI*V V,Uoij(: $TATEOF IINNANA <br />My Commission Expires: P"'T j(),,Em; coutqlry <br />Residing in County, my (",(;)MOISSIONa drXF'IRE S 1011011 <br />8 Notary Public Name <br />