Change Order & PCA - 12th Floor Remodel Proj No 116-125 - Brown & Brown General Contractors

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State of Indiana, County of Final Waiver of Lien Elkhart SS: Eric Brown being duly sworn that he/she is the President (Name of Officer) (Title) of Brown & Brown General Con tractKlrgcontracted with City of South Bend, IN (Contractor) (Owner) to famish certain materials and/or labor as follows: tear down and build of several walls, carpet, paint (Deacrlption) for a project known as Remodel of 12th floor (Name of Project) located at 227 W. Jefferson Blvd., South Bend, IN and owned by City of South Bend, IN (Owner) and does hereby further state on the behalf of the aforementioned subcontractor/supplier: (PARTIAL WAIVER) that there is due from the Contractor the sum of Forty-one thousand seven hundred sixty-eight and 00/100 Dollars _($ )00 ❑ receipt of which Is hereby acknowledged; or the payment of which lies been promised as the sole consideration for this Affidavit and Final Waiver of Lienwhich is given solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the undersigned; (FINAL WAIVER) that the final balance due from the contractor is the sum of _($ ] ❑ receipt of which is hereby acknowledged; or ❑ the payment of which has been promised as the sole consideration forthis Affidavit and Final Waiver of Lien which shall become effective onlyuponreceipt of such payment. THEREFORE, the undersigned waives and releases unto the Owner of sold promises, any aed all liens or claims whatsoever on the above -described property and improvements thereon an account of labor or material or both, furnished b the undersigned thereto, subj act to limitations or conditions expressed herein, if any; and further certified that no other party has any claim or right to a lien on account of any work perfbnned or material famished to the undersigned for said project, and within the scope of this Affidavit and Waiver of Lien. Brown & Brown General Contractors, Inc. Ey I L (l) uthorize Representative) 9;,/ STATE OF INDIANA ) ) SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, In and for said County and State, personally appeared and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHSREOF, I have hereunto subscribed my name and affixed my official seal on the March 200 17 My Commission hkpirm: 3 / 1 / 2 019 Eric Brown Notary Public Signature -- Bradley A. Romine Residing in St. Joseph County, IN Notary Public Name 8th day of