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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of S (- _W'O,6� _ SS: <br />being duly sworn that he/she is the <br />(Name of Officer) (Title) <br />( trhaving contracted with C t-�� O� S �-� �� � <br />of ►�' So or... _„ ... (C-,eaetei j� <br />to furnish certain materials and/or labor as follows: <br />for a project known as A, <br />located at <br />and owned by <br />(Description) <br />(Name of l,' <br />604A—T,-J ���L�v vo.ti✓� <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 />E] 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 is the sum of <br />f( _,.,.... <br />_.:.. .. m.. <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 />(Authorized Representative) <br />STATE OF INDIANA ) <br />SS: <br />ST. JOSEPH COUNTY ) / <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 />b 200 a ( al on the "% day of <br />. _ ,........._.. �.... scribed my name, and WITNESS WHEREOF I have hereunto subscribed y official se . � Mµ <br />�......X affixed m o <br />Notary Public Signature <br />My Commission Expires: ..�L......._..... _ MARSHA L. 11fi01 <br />ResidingPublic, State of In?, a <br />County <br />of St losefi <br />m � <br />. County, _�_ ... _.�, _ wmmITm _ SEAL Notary Public Name <br />am mission 14 (441!74 2021 <br />