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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of S4 • `/D SS: <br />being duly sworn that he/she is the le S <br />(Name of Officer) (T&) <br />avn, contracted with <br />of . 6� g ��.__ <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: 'D4 "-A t <br />(Description) <br />for a project known as / C sr� ' ' r a" `61 I .)-0 -y' <br />/ (N me ofProject) <br />located at <br />and owned by, <br />(Owner)L U C IRA <br />Sam <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier: Nary public • ma10 of Irani <br />6t Jo�It .County <br />(PARTIAL WAIVER) that there is due from the Contractor the sum of CO�tlarr Oct 22w 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 />7W9!KR9 <br />e due fromsct rJ(Sowledged; or <br />IfA <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 Runished to the undersigned for said project, and within the scope of this Affidavit <br />and Waiver of Lien. <br />=ALkL4 4715 -� u By <br />(F) )e ' eS �e sir <br />STATE OF INDL4NA <br />SS: <br />ST. JOSEPH COUNTY ) / <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared.Jo5AL)a 4 z 6o &qrc <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 seal on the �� day of <br />Notary Public Signature <br />My Commission Expires: L� d C;ko A <br />Residing in County, �G �✓t4 Notary Public Name <br />