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Project 116-067 <br />0 Final <br />AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of St. Joseph, SS: <br />❑ Partial ❑x Payment to Follow <br />Jennifer M. Brown being duly sworn states the she is the Corporate Secretary of Ideal Consolidated, Inc., having <br />contracted with City of South Bend. to furnish certain materials and/or labor as follows: HVAC Work for a project <br />known as Fire Station #7 HVAC, located at South Bend, IN and owned by the City of South Bend and does hereby <br />further state on behalf of the aforementioned subcontractor/supplier: <br />(PARTIAL WAIVER) that there is due from the contractor the sum of: <br />Dollars ($.00) <br />( ) receipt of which is hereby acknowledged; or <br />( ) the payment of which has been promised as the sole consideration of this Affidavit and Partial <br />Waiver of Lien which is given solely with respect to said amount, and which waiver shall be <br />effective only upon receipt of payment thereof by the undersigned: <br />(FINAL WAIVER) that the final balance due from the contractor is the sum of: <br />Eleven Thousand Seven Hundred Sixty Dollars ($11,760 00) <br />() receipt of which is hereby acknowledged; or <br />(X) the payment of which has been promised as the sole consideration for this <br />Affidavit and Final Waiver of Lien, which shall become effective upon receipt of such payment. <br />THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all lien or claim <br />whatsoever on the above -described property and improvements thereon on account of LABOR or material or both, <br />furnished by the undersigned thereto, subject to limitations or conditions expressed herein, if any; and further <br />certifies that no other party has any claim or right to a lien on account of any work performed or material furnished <br />to the undersigned for said project, and within the scope of this affidavit and waiver. <br />Idea! Consolidated, Inc. Corporate Secretary <br />By Title: <br />Firm Aluth rizedRepresentative <br />Jlgnyifer M. Brown <br />WITNESS MY HAND AND NOTARIAL SEAL, this 4th day of November 2016. <br />My commission expires: 08/01/22 <br />Residing in St. Joseph County <br />� &a <br />Notarjl Public <br />Printed: Mary A. LaPlace <br />... ... <br />... <br />MARYA. LAPLACE <br />`moinnr'• :Notary Public, state of Indiana St. Joseph County <br />sEni : g Commission # 654785 <br />MY Commission Ezpires <br />"a„.n "' August 01, 2022 <br />