APPENDIX S: WAIVER OF LIEN AND AFFIDAVIT OF PAYMENT FORM

(when posting Maintenance Bond)

Comes now                                         by and through                                   , as its representative

and being duly sworn upon his oath states the following:

   1.    That                                       is the developer of a certain subdivision within the County of Hancock, Indiana, known as                                         .

   2.   Contained within said subdivision is certain infrastructure and other improvements designed by developer and its engineers and installed by the developer and those persons or entities listed on Exhibit "A". Said infrastructure and improvements shall include streets, sidewalks, sewers, landscaping, lighting, and any other infrastructure located within an easement or right-of-way dedicated to the County of Hancock, Indiana.

   3.   That attached hereto and incorporated herein is Exhibit "A" being a list of all independent contractor, subcontractors, mechanics, and/or material men who provided any goods, labor, or services in any manner associated with the design and/or installation of the infrastructure and/or improvements referred to above.

   4.   Affiant, by his signature below, on behalf of the developer and those persons or entities listed on Exhibit "A" hereby waives all legal rights to file any type of lien whatsoever against the real estate within or on which the aforementioned infrastructure and/or improvements is located and furthermore represents and warrants that all persons and/or entities on Exhibit "A" have been paid in full all sums due them for the design and/or installation of said infrastructure and/or improvements.

   5.   Affiant further warrants and represents that each person and/or entity on Exhibit "A" has been notified by the developer in writing in advance of the signing of this Affidavit that developer intends by this Affidavit to waive any and all lien rights that may exist on behalf of all those listed on Exhibit "A" and has not received any objection to the execution of this Affidavit from any representative of those listed on Exhibit "A".

AND FURTHER AFFIANT SAYETH NOT.

I swear under the penalties of perjury that the above and foregoing is true .

(Name of Developer)

Comes now                                and acknowledges his signature as set forth above this          day of                         , 20      .

Subscribed and sworn before me, a Notary Public, in and for said County and State, this              day of                    , 20     .

Notary Public

County of Residence

Commission Expiration

(Ord. 2003-10F, passed 10-12-03)