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�+State of Indiana, Cot:nty of ! A (Z t cjv." _ SS: <br />( 2 ` tj� ("j m Ax) being duly sworn that h0he is the A—P <br />tC 'a <br />(Name of Officer)' C (Title) <br />of /V4r4ytA1 �e�4'i=(�lr�� having contracted with G 1-(f'o <br />(Contractor) I (Owner) �'� r <br />to furnish certain materials and/or labor as follows; AQ� �� 4 ' ''4 04 5 � �� �u sF€r< k,Q O I) KL"-'� C1 <br />(Description) yy-. <br />for a project known as F1Atwo�t_''-�/�r."/i1/ <br />(Name o ng)eot) f <br />located at � f "r%k 6 q iE -r-G •, 14 � �T_Z_ n t s _5 <br />and owned by- <br />(Owncr) <br />and does hemby lhrther 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 />1_( receipt of which is hereby aelatowledged; 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 />(FINA WAIVEthat the finfrom the balanco due frothe contractor is the sum of C, <br />A) <br />receipt ofwhioh is hereby acknowledged; or <br />[� the payment of which has been promised as the sole consideration for this Affldavit 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 &a 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 famished to the undersigned for said project, and within the scope of this Affidavit <br />and Waiver of Lien. <br />� t AC _ i V t fti �r�T �' l fd�' �tv By CA <br />- (Firm) (Authorized Representative) <br />STATE OF INDIANA ) J y ��, `•� �, . <br />SS. <br />ST. IOSEPH COUNTY <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared tom` <br />and aelutowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />WITNESS WHEREOF, I have hereunto subscribed my name and affixed my ofiieill Wei on the 2- day of <br />202 <br />—.�.�� <br />Notary Public Signature <br />My Commission Expires: ._ / U Z'?- Z e) 2y <br />Residing in l A�/_Ipr! County' .�—n� �) 1 A --_ <br />Notary Public Name <br />CURT S PICKARD <br />F <br />tary Public - Seal <br />ounty - State of Indi]2030 <br />ion Number NP0744ssion Expires Oct 21, <br />