Fill and Sign the Indiana Lien in Form

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 in full for labor performed and/or materials furnished by __________________________________ for the following improvements,       to the property located at: Street Address: ________________________________________________ Legal Description:       By this document the undersigned lien claimant hereby releases any lien it may have in connection with the above - described property for labor performed and materials furnished. Discharge of Lien Page 1 of 3 Signature of Lien Claimant       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 Discharge of Lien 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       Discharge of Lien Page 2 of 3 Print or Type Name Print or Type Name Discharge of Lien Page 3 of 3