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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of SS: <br />being duly sworn that he/she is the <br />(Name of Officer) (Title) <br />of having contracted with Z�J�A " L% <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: k <br />(Description) <br />for a project known as <br />�... <br />(Name of Project) <br />located at ~" <br />and owned by C .. 7 A � <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 />(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 if'ed that no other party has iainra or right to a <br />lien on account of any work performed or material furnished to the undersign for s "d project, and wit a scope of this Affidavit <br />and Waiver of Lien. <br />By <br />(Firm) <br />STATE OF 1NDIANA (Authors " d Representative) <br />SS: <br />ST. JOSEPH COUNTY ) `" <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 Wl µ'NESS �-� 200yJ ythe day of <br />hereunto subscribed m name and affixed m :offlc' <br />ALICE M. Mc I dLEY <br />NOTARY PUBLIC - INDIANA <br />ST. JOSEPH COUNTY Not Public ignature <br />m „a My Comm. Expires 9/26I2024 ! <br />My <br />................ <br />Residing in _ County, <br />" '6- � <br />Notary Public Name _ <br />