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AFFIDAVIT AND WAIVER OF LIEN <br />01 <br />State of Indiana, County of or Jo s:w h SS: <br />being duly sworn that he/she is the /C S tr <br />(Name of Officer) (Title) <br />.f/,O, &Vh , 'e, 6 .' having contracted with 66 JIM &nd <br />(Suticontractor/Suppliel�) (Contractor) <br />to, furnish certain materials and/or labor as follows: ayss 1,0alk <br />(Description) <br />for a project known as <br />(Name of Project) <br />located at /b 4.), � rle'q P, <br />and owned by <br />Y7 A5: jefLd (Owner) A a M 0 0 <br />=SUE ANNE CIR�A <br />Soil <br />1401 y <br />Notary Public - Sidle lot =11adlaho <br />no <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier: St Jos"h 0 <br />St Joseph County <br />(PARTIAL WAIVER) that there is due from the Contractor the sum of M Ca MOO EXPIRS 00122, 2022 <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 />70 <br />due from the contractor is the sum of <br />fian $ —c—, <br />receipt of which is hereby acknowledged; or <br />3 (2'e5 <br />X. I -A <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 promises, 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 further certified that no other party has any claim or right to a <br />lien on account of any work performed or material famished to the undersigned for said project, and within the scope of this Affidavit <br />and Waiver of Lien. <br />By <br />a ive (Firm) (A:u 0, t t <br />STATE OF INDIANA <br />) SS: <br />ST. JOSEPH COI.JNTY <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 nalrte and affixed my official seal on the day of <br />Notary Public Signature <br />My Commission Expires: <br />Residing in14 d, a nqCounty, 5�Js P�_ _-Notary Public _Kame <br />