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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of _ ST, FUSE SS: <br />caw_— being duly sworn that he/she is the Acc*, <br />(Name of Officer) (Title) <br />of C65 5E2VlCE L- _c having contracted with G (ry oF- 5-v —,,v( gE N*) <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: ELEG0-7?Z A'L <br />2 (Description) <br />for a project known as �Nt~ of PrT ?Xaun/ 1?0' C_ <br />(Name of Project) <br />located at &W 500-14 66NO (IV 46401 <br />and owned by A NDaeuv 2ozuv <br />(Owner) 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 />�.www <br />Dollars($ �mm <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 b}' the <br />undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor is the sum 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 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 said project, and within the scope of this Affidavit <br />and Waiver of Lien. <br />C 0 5 5ee-✓! C E Lc.0 By <br />(Firm) --g'(Authorized Representative) <br />STATE OF INDIANA ) <br />SS: I/ D <br />ST. JOSEPH COUNTY ) <br />11L /�y l <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared <br />acknowledged the execution of the foregoing Affidavit and Waiver of <br />IN <br />anIN WITNESS WHEREOF, I have hereunto subscribed my name � � 1 seal on th � day of <br />20/ <br />�1 S igna ure <br />My Commission Expires: t ✓ ,�,_� ; ` = /� <br />Residing in � County, � ,p�~ , ,�� <br />'" T OF Fu Name <br />