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AFFIDAVIT AND WAIVER OF LIEN <br />State ofdarart'a, +bounty of <br />_...� T / <br />M� e-" 1 being duly sworn that he/she is the t, <br />(Name of Officer) %(Title) <br />of having contracted with ) u <br />(Subcontractor/Supplier) <br />(Contractor) <br />to furnish certain materials and/or labor as follows: _ <br />(Description) <br />fora project known as <br />p J , . .� E_actio�h. <br />(Name of Project) <br />located at <br />and owned by <br />(f (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 />L� 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 />WAIVER) that the final balance due from the contractor is the suin 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 ortt <br />"',famished b the undersigned <br />thereto, subject to limitations or conditions expressed herein, if any; and further certified that x her party has any claim or right to a <br />lien on account of any work performed or material furnished to the undersigned for sa" proj t, and itltin t." scop f is Affidavit <br />and Waiver of Lien. <br />y <br />(F) STATE OF 1NDIANA (Authorized presentative) <br />) <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 />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the dayof <br />200� 19 <br />Notary Public Signature <br />My Commission Expires: ,m <br />Residin in <br />g Zn�5;" County, �° �„ � , r,� � _ _ Notary Public Namner'' <br />