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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of Y1SS: <br />being duly sworn that he/she is the 3q4 we <br />(Name of Offi er) (Title) <br />of Ile L11 Z having contracted with <br />.1?44 &14, V trac _ <br />(Subcont-ractor/Supp,lier) (Contractor) <br />to furnish certain materials and/or labor as follows: <br />(Description) <br />I <br />for a project known as <br />�7- <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 />11 receipt of which is hereby acknowledged; or <br />El 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 />"x <br />receipt of which is hereby acknowledged; or <br />El 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 bptl), furnished b the undersigned <br />11 <br />thereto, subject to limitations or conditions expressepla? AN�' and further certified flarn' tither party has any claim or right to a <br />lien on account of any work performed or materi r6s ,Nersigned for s fro` t, and w' i the scope of this Affidavit <br />and Waiver of Lien. <br />C) 1. <br />p 0 RA r. <br />:By <br />-;Ac C011� <br />(Firm) <br />(Authorized Representative) <br />STATE OF 11N LJ1,ft1Nft <br />ST. JOSEPH COUNTY D� <br />Before me, the undersigned, a Notary Public, in an for id County and State, personally appeared <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITN�SS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the <br />�-S74 <br />AMY ELIZABETH TLAP4 <br />Notary Public, State of <br />Marshall county 7N <br />Commission Expres <br />My Commission Expires- June 71 2023 <br />Residing in —p—N �VA2A County, 1 Notary <br />is Signature <br />� V I 6t4' <br />c Name <br />day of <br />