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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of t^ SS: <br />(Name�of Officer) "being duly sworn that he/she is the _� E� <br />mw <br />(Title) <br />of �...._ having contracted with ��.. (�....�C U t�C . <br />J (Subcontractor/Supplier) (Contractor) <br />to furnish furnish certain materials and/or labor as follows: S <br />R C /� (Description) <br />for a project known as E?14....._ �l -6 5 9 !p <br />p 1 I (Name of Project) ,, I <br />located at C <br />and owned byt�_ <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 .A � �? ..� _..... —.._ ...... <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 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 />4AA - <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 s, id project, an within the scope of this Affidavit <br />and Waiver of Lien. <br />_ �_Ati? f 9 G-C r I ..­. By _.... - ((Firm) Authorize Representativee <br />) <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 G f3 E /_Q LJ E <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 { day of <br />Notary �,SCaturP <br />My Commission Expires. �. �r� �, �E � � � �E <br />g tY C' �d _.._ _ --Not ,`�4.. L e <br />Residing m 1 Coun <br />