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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of SS: <br />being duly sworn that he/she is the Re suqq <br />(Name of Officer) M <br />of V f k <br />-fM —1P having contracted with <br />(Stibcontractor/Supplier) <br />(Contractor) <br />to furnish certain materials and/or labor as follows: PAL A <br />for a project known as <br />(Name <br />located at I <br />and owned by <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 />!n., 4 —tt A <br />eject) <br />Dollars <br />El receipt of which is hereby acknowledged; or <br />El 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 contractor is the sum of <br />. ....... . . . ..... <br />El receipt of which is hereby acknowledged; or <br />Ck 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 improvernerns thereon an account of labor or material or both, fumijiled b the undersigned <br />thereto, subject to limitations or conditions expressed herein, if any; and furtlier certified that no other parry has any clahn or right to <br />lien oil 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 />—.0 <br />(Firm) uthori presentative) <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 />INJITNESS WHEREOF, I have hereunto subscribed my name and affixed rn 7yffllcial sea] on the <br />A, day of <br />200 120101� ly, <br />Notary Public -§17J!Fn8-tTe <br />MY Commission Expires: <br />Maltv <br />M <br />Residingn <br />------- County, <br />erne <br />Irais �Mariela Galvan <br />al Notary Public Seal State of Indiana St J, ep County <br />St joseph <br />Commission <br />11 <br />M M, Coo","�', 0/16 <br />v Coomssion Exoires 07/16/2025 <br />