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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of SS: <br />,F� _ m g duly sworn that he/she is the 1 '& t a O-J <br />V <br />(Name of Office,........ n�..............� _.�. ..�.. �_� . <br />r) (Title) <br />�, .�..e.. <br />of 'eA- _ having contracted with U-P <br />�.. Subcontr to0Su leer <br />( <br />pp ) CC? rclCr4?1 <br />to furnish certain materials and/or labor as follows; <br />.�.�Dcst.ir �tio� ..... _..rc � . � .� ..�.�� ... <br />for a project known as f� ( 1 .�) /� n <br />....W. �.�.... ._....� ........ _ <br />12 _ �� (Name of Project) <br />located at w ..w...,. _ <br />and owned b e f _ <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 />(FINAL WAIVER) that the final balance due from the contractor is the sum of <br />r � l <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 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 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 the scope of this Affidavit <br />river of Lien. <br />..................... <br />(Firm) Catrrirr7���x r rf �A�i 31 art P IC( <br />axed Mega-eseatative) <br />STATE OF INDIANA ) Y <br />i <br />SS: Re,ides in S. Jo,epfr Co., 6N <br />ST. JOSEPH COUNTY ) R 4�r�a. Nudrn�er 672377 <br />Before me, the undersigned, a Notary I'ubltc„ in ari or sai ounty and State, personally appeared <br />an <br />IN IT"ed the execution of the foregoing <br />WHEREOF, I have hereunto subscribed my name and affixed my official seal on the 2� ^day of <br />acknowledged Affidavit and Waiver of Lien. <br />INj200 <br />Notary Public Signature <br />My Commission Expires: 'Akq <br />Residing in I V County, t V <br />............. ........ <br />Notary <br />� ... Public Name �_ �........ <br />o ary me <br />