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ISA Farm # 1.402 <br />PREPARE IN DUPLICATE <br />Orlglnal - Contractor <br />Dupilcate - Subcontractor/Supplior <br />AFFIDAVIT AND WAIVER OF LIEN <br />IK Final 0 Partial liil Payment to Follow. <br />State of Indiana. County of St. Joseph SS <br />Randall H. Rice being duly sworn states that he is the Asst. Secretary of <br />iName of dtircerp {True) <br />Gibson -Lewis, LLC having contracted withCto furnish, certain <br />(Subconiractor,•Supphed 1Contractorl <br />materials and/or labor as follows Sus Shelters <br />(t7e&Crlpil <br />for a project known as .. 0611t v of South. Bend Bus Shelters 2016 <br />located at <br />South Bend IN <br />and owned by City of South Rend Bird of Public Works <br />l0wnar► <br />and does hereby further ;state on behalf of the aforementioned subcontractorfsupplier: <br />[ j receipt of which Is hereby acknowledged; or <br />} the payment of which has been promised as the sole consideration of this Affidavit and Partial Walver of <br />Lien which is given solelywith respect to said amount, and which waiver shall be effective only upon receipt <br />of payment thereof by the undersigned; <br />tFINAL'Vil'AIVIER) that the final balance due from the contractor is the sum of <br />Fifteen Thousand Twenty Seven Dollars and 07/100 Dollars is 15,027.017 <br />receipt of which, Is hereby acknowledged; or <br />[X 1 the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of <br />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 whatsoever <br />on the above -described property and improvements thereon on account of LABOR or material or both, furnished by the <br />undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certifies that no other party <br />has any claim or right to a lien on account of any work per ed cir material furnished to the undersigned for said project, <br />and within the scope of this affidavit and waiver. Titl <br />P­­ <br />eewis, LLC By + Asst. Secretary <br />Gibson-L6.�,,.. <br />_ <br />i Firmi fAuthorsaed Representative! <br />WITNESS MY HAND AND NOTARIAL SEAL, this <br />My Commission Expires _ July 10, 2024 <br />Residing in — St. J eph�__ .,­ County <br />0 1979 iNOIANA SUBCONTRACTOR$ ASSOCIAPON INCORPORATED <br />Unsulhonled Reproduction Prohibited <br />Oth y of (November _ 20 17 <br />rry <br />� <br />v- w�...irr ,INatary. <br />Pubhcl <br />Printed. <br />Elizabeth A. Biddle <br />rurr,,,, ELIZABtTH A, BIDDLF <br />va <br />�R„ °��<F` Niotary Pulalic, Staie of Indiana <br />;SEAL r St. Joseph County <br />11y Commission Gxpiros <br />f'+asrti 1'`~ July 10, 2024 <br />Rev 10ill••2 <br />