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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of St. Joseph SS: <br />Rachelle L, Dolniak being duly sworn that he/she is the President <br />(Name of Officer) (Title) <br />of Ritschard Bros., Inc. having contracted with City of South Bend, Board of Public <br />(Subcontractor/Supplier) (Contractor) Works <br />to furnish certain materials and/or labor as follows: Clearing, Material, Asphalt Paving <br />(Description) <br />for a project known as Potawatomi Zoo Parking Lot Expansion <br />(Name of Project) <br />located at 500 S. Greenlawn Avenue, South Bend, IN <br />and owned by City of South Bend, Bureau of Public Construction <br />(Owner) <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier: <br />(PARTIAL WAIVER) that there is due from the Contractor the sum of <br />Dollars _($ ) <br />❑ receipt of which is hereby acknowledged; or <br />❑ the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which is given <br />solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the <br />undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor is the sum of One Hundred <br />Ten Thousand Four Hundred Seven Dollars & 60/100----------- ($110,.407. O <br />❑ receipt of which is hereby acknowledged; or <br />© the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shall <br />become effective only upon receipt of such payment. <br />THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all liens or claims whatsoever <br />on the above -described property and improvements thereon an account of labor or material or both, famished b the undersigned <br />thereto, subject to limitations or conditions expressed herein, if any; and her certified that no other party has any claim or right to a <br />lien on account of any work performed or material fumished to the under i ed for said project, and within the scope of this Affidavit <br />and Waiver of Lien. <br />Ritschard Bros., Inc. By <br />(Firm) (Authorized Representative) <br />STATE OF INDIANA ) <br />) SS: <br />ST,JOSEPH COUNTY <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Rachelle L. Dolniak <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITNESS WHEREOF, I have hereunto subsc�ingq ffV name and affixed my offic; seal on the 16 th day of <br />January A4W' Gl7. <br />O T'q Notary Public Signature <br />��..� <br />My Commission Expires: 9 / 18 / 17 <br />Robin Fozo <br />Residing in St. Joseph County, hn&tapa &LIG Notary Public Name <br />Op IND1P�a "\ <br />