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State af7ndiana, Gounty of ��%�� SS: <br />X�`_ �� �� bahtg duly sworn that he/she !s tho ail (� — Qi2�i �(.2f1,�' <br />{Name of ftloer) (Title) <br />f <br />:�� � :,� <br />for a project known as <br />having contracted with G p � , <br />(Owner) <br />and does hea�eby flusher state on the behalf ofthe aforemendoued subcontractorJsuppller; <br />(PARTIAL WAIVBR) that ther8 is due from Hio Contractor the sum of <br />Dollars ,�($ ) _� <br />❑ receipt of which is hereby acin►owledged; or <br />❑ the payment of which has been promised as the sole consideration fox this Af�dsvlt and Final Waiver of Llenwhlch is given <br />solely with respect to said amount, and which waiver shall be effective only upon receipt ofpaymentthereof bythe <br />undersigned; <br />�: � .� � �. <br />L V► ..�.�- .-� ,,� .�.� .•� �► �� �. � r <br />❑ receipt ofwhich is hereby eolmowledged; or <br />the payment of which has been promised as iha sole consideration for this Atliidavlt and Fiaa! Waiver of Lien whioh shalt <br />beoome offeotiva on;4y uponreceipt of suoh payment. <br />THBitRFORB, the undersigned waives and releases unto the Owner of said premises, any and al! liens or claims whatsoever <br />on the above -described property and improvements thereon au account of labor or material or both, t%rnished b the unders[gned <br />thereto, subject to limitations or conditions expressed hereia, if any; and further certified ihatno other party has any claim or right to a <br />lien on eccount of any work performed or material iitrnishad to the undersigned for said project, and within the scope ofthis Affidavit <br />and Walvcrofiiem. <br />'�� � <br />:, „� <br />.: . <br />~ _ 1 <br />a, <br />� r,, , t <br />., .� M , <br />SEAL <br />ELKHART COUNTY, STATE OF INDiANA <br />MY COMMISSION EXPIRES FEBRUARY 12, 2026 <br />COMMISSION NO.710399 <br />