"Waiver of Lien Partial Form" - Indiana

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Download "Waiver of Lien Partial Form" - Indiana

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WAIVER OF LIEN
PARTIAL
State of Indiana
)
) SS:
County of __________________ )
WHEREAS, the undersigned _____________________________________________________________,
(hereinafter referred to as "Contractor") has been heretofore employed by _________________________________
_________________________________________________________ to furnish certain material and labor, to wit:
____________________________________________________________________________________________
____________________________________________________________________________________________,
for the building and real estate owned by ___________________________________________________________,
and located at the premises commonly known as _____________________________________________________
________________________________________ in _________________________ County, State of Indiana.
NOW THEREFORE, KNOW YE, that the undersigned Contractor, for good and valuable consideration of
$_______________________________________, the receipt of which is hereby acknowledged, hereby and now
waives and releases unto said owner(s) of said building and real estate, any and all liens, rights of liens, or claims
of whatsoever kind of character on the above referenced building and real estate TO AND FOR SAID AMOUNT,
on account of any and all labor, services, and material furnished for or incorporated into said building and real
estate by the undersigned Contractor up to the date of this waiver; and the undersigned Contractor further certifies
that the consideration moving to the undersigned for executing this Partial Waiver of Lien has been mutually
given and accepted as partial payment to or on account of the undersigned Contractor for said material and/or labor.
Date: ________________________________
Contractor: ________________________________________________________
(printed name )
By: _____________________________________________________________
(signature)
Printed name and title: ______________________________________________
Before me, the undersigned Notary Public in and for said County and State, personally appeared the within
named _____________________________________________________________________________________, as
_______________________________________, for and on behalf of ____________________________________,
the Contractor, and acknowledged the execution of the foregoing Partial Waiver of Lien and who, having been
duly sworn upon his/her oath, stated that the representations contained therein are true.
Witness my hand and Notarial Seal this ______ day of _______________________, 20___.
Notary’s Signature: _____________________________________
Notary’s Printed Name: _____________________________________
Notary’s County of Residence: _________________________
Notary’s Commission Expires: _________________________
WAIVER OF LIEN
PARTIAL
State of Indiana
)
) SS:
County of __________________ )
WHEREAS, the undersigned _____________________________________________________________,
(hereinafter referred to as "Contractor") has been heretofore employed by _________________________________
_________________________________________________________ to furnish certain material and labor, to wit:
____________________________________________________________________________________________
____________________________________________________________________________________________,
for the building and real estate owned by ___________________________________________________________,
and located at the premises commonly known as _____________________________________________________
________________________________________ in _________________________ County, State of Indiana.
NOW THEREFORE, KNOW YE, that the undersigned Contractor, for good and valuable consideration of
$_______________________________________, the receipt of which is hereby acknowledged, hereby and now
waives and releases unto said owner(s) of said building and real estate, any and all liens, rights of liens, or claims
of whatsoever kind of character on the above referenced building and real estate TO AND FOR SAID AMOUNT,
on account of any and all labor, services, and material furnished for or incorporated into said building and real
estate by the undersigned Contractor up to the date of this waiver; and the undersigned Contractor further certifies
that the consideration moving to the undersigned for executing this Partial Waiver of Lien has been mutually
given and accepted as partial payment to or on account of the undersigned Contractor for said material and/or labor.
Date: ________________________________
Contractor: ________________________________________________________
(printed name )
By: _____________________________________________________________
(signature)
Printed name and title: ______________________________________________
Before me, the undersigned Notary Public in and for said County and State, personally appeared the within
named _____________________________________________________________________________________, as
_______________________________________, for and on behalf of ____________________________________,
the Contractor, and acknowledged the execution of the foregoing Partial Waiver of Lien and who, having been
duly sworn upon his/her oath, stated that the representations contained therein are true.
Witness my hand and Notarial Seal this ______ day of _______________________, 20___.
Notary’s Signature: _____________________________________
Notary’s Printed Name: _____________________________________
Notary’s County of Residence: _________________________
Notary’s Commission Expires: _________________________