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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of IJT "Ked 6111W SS: <br />being duly sworn that he/she is the <br />(Name of Officer) <br />(1`l w <br />�� (Title) <br />of having contracted with ��� c!'Od�fss ,( <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: <br />(Description) <br />for a project known as <br />(Name of Project) <br />located at, <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 />Dollars <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 />WAIVER) that the fmal 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 rsaid <br />r both, furnished b the undersigned <br />thereto, subject to limitations or conditions expressed herein, if any; and further o other party has any claim or right to a <br />lien on account of any work performed or material famished to the undersignede�tg and within the scope of this Affidavit <br />and Waiver of Lien. <br />L I N DA dYGI <br />Niotaty Public, State o� Mrrpr� <br />F 1NDIANA )L7' sr. Joseph f ourbry . " .._.. <br />SS: ,*�a,» Commission Number NP07210A. <br />ST. JOSEPH COUNTY <br />`" " 11111" ar `"'w My clulV 3t' 20 1on pires <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 />IN WITNESS WHEREOF, I have hereunto subscribed my <br />name and affixed my official seal on the 40»1 day of <br />20gr <br />Notary Pubhc ignature <br />My Commission Expires:_~�� <br />Residing in J'1 �('�}�/� County, <br />(,�_ ty,� Notary Public Name <br />