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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of 14. L ^lpe SS: <br />a <br />W being duly sworn that he/she is the Vreswt <br />(Name ofOfficer(Title) <br />of having contracted with 1 <br />( <br />bcontractor/Supplier) (Contractor) <br />cc <br />to famish certain materials and/or labor as follows: "� � � � <br />(Description) <br />4-1 <br />for a project known as V V� �V 1 <br />(Name of Project) <br />located at <br />and owned by 1'�� <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 />that the Tina ba n e duOVW <br />e�ftom,�co as or is the sum of� $ <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 sco a of this Affidavit <br />and Waiver of Lien. <br />n By <br />C , (Ruth rled R rese i� d <br />(Fi) ' ) <br />STATE OF 1N IANA <br />SS: <br />ST. JOSEPH COUNTY _ <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared � n �c„ „ eg <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. p <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official se on the / day of <br />i �. <br />Not Public Signature <br />My Commission Expires: <br />Residing in - County, Notary Public Name <br />