Fill and Sign the Indiana Discharge 497306838 Form

Partial Discharge of Lien-Individual (I.C.A. § 32-28-1-1) On this _____ day of ________________ , 20 ______ , the undersigned does hereby acknowledge receipt of payment from __________________________________ in the amount of $ ______________ which represents payment for ________________________________________________________________________ (descri be the specific labor performed and/or materials furnished) by __________________________________ for the following improvements:       to the property located at: Street Address: ________________________________________________ Legal Description:       This document is a discharge of _________________________________ , a portion of the mechanic’s lien which the lien claimant has in connection with the above - described property for the labor performed and materials furnished. Partial Discharge of Lien Page 1 of 3 Signature       Type or Print Name STATE OF INDIANA ,       County, ss: Before me, the undersigned, a Notary Public in and for said County and State, personally appeared the within named       , who acknowledged the execution of the foregoing __________________ and who, being duly sworn, stated that the representations therein contained are true. Witness my hand and       Seal this       day of       , 20       . Notary Public. Resident of       County. My Commission expires       , 20       This Instrument was prepared by:                   Affirmation Statement I affirm, under the penalties for perjury, that I have taken reasonable care to redact each Social Security number in this document, unless required by law. Signature       Signature       Partial Discharge of Lien Page 2 of 3 Print or Type Name Print or Type Name Partial Discharge of Lien Page 3 of 3