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F1 <br />State of Indiana. County of <br />Jeff Bucher, Jr. <br />(Name of Officer) <br />ISA Form # 1-402 <br />PREPARE IN DUPLICATE <br />Original - Contractor <br />Duplicate - SubcontractGr/SuppIler <br />AFFIDAVIT AND WAIVER OF LIEN <br />J0 Final 10' Partial Payment to Follow. <br />St. Joseph SS: <br />being duly sworn states that he is the Vice -President _ of <br />little) <br />Edward J. White, Inc. having contracted with C4-,,J to furnish certain <br />iS ubcontracior,'Supplier) 0 (Contractor) <br />materials and/or labor as follows: mechanical material and labor <br />t known as dDescriptil") L L <br />fora projeccmS 0 il <br />located at l�05, At, A4,, A LA �0,80­u/ rand owned by Ckr S',41 A"J &,,4 d 64/,�:- 11,h-S <br />C) 0 lOwnerl <br />and does hereby further state on behalf of the aforementioned subcontractorlsupplier; , <br />(PARTIAL WAIVER) that there is due from the contractor the sum of <br />Dollars ($ <br />[ ] reoeipt of which is hereby acknowledged; or <br />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 waivershall be effective only upon receipt <br />of payment thereof by the undersigned; <br />(FINAL 'WAIVER) that the final balance due from the <br />'nMez vlooS40 F-0t.4- 401v6PZC-0 Ptr--TZFCW A,,jg�N 0 ­2 <br />ractor is 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 <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 />i Form) <br />Bye ~ Title Vice -President <br />% (AuYh6rued Flepr6entatwe) <br />WITNESS MY HAND AND NOTARIAL SEAL, this zl�m 0 Yl^ - day of JU I-e. - .20 t A <br />My Commission Expires: August 10, 2.021Z <br />Residing in _ St. Joseph County <br />0 1979 INDIANA SUBCONTRACTORS ASSOCIATION. INCORPORATED <br />Unauthorized Ropraduclion Prohibited <br />Notary <br />E. Tay for <br />R6Vr IM2 <br />