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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of <br />_J4 <br />IV <br />i <br />(Name of Officer) <br />of "-"" <br />(trbcorttractor/Stmpp]ier) <br />to furnish certain materials and/or labor as follows: <br />SS: <br />being duly sworn that he/she is the S <br />(Title) <br />.4 ee_ <br />having contracted with-��'�^�~'� l��ynA0L1PC <br />(Contractor) <br />(Description) <br />for a project known as <br />(Nance of Project) <br />located atw,s I< -44 <br />and owned by <br />__2_......._.......e�.. _ . �m.. ._.. n ........ _ - _. _ <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 fiom the contractor is a sum of the A— <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 />and Waiver of Lien. <br />By <br />�, t ..�1­0�-��CA`at _. ..—. tativSTATE OF INDIANA�Ii ) ) " f t os, � Pu1114C toai ed Representative) <br />SS. <br />i (, 2023 <br />ST. JOSEPH COI rN";Cy �' "ins�., iN . <br />Before me, the undersigned, a Notary Public, in ail" for spar , in y t nr State, personally appeared ' <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN subscribed my*name and affixed my official seal on the day of <br />..M.. <br />WITNESS WHEREOF, I havehereunto <br />200 � q <br />Ui�ff6ublXicS�itjrdttac <br />My Commission Expires: '' <br />Residing in _. rCounty, -�� Notary Public Name <br />._....._ <br />