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ISA Form # 11-402 <br />State of IN <br />Frank D. Feichter <br />PREPARE IN DUPLICATE <br />Original - Contractor <br />Duplicate - Subcontractor/Supplier <br />AFFIDAVIT AND WAIVER OF LIEN <br />final F-1 Partial L-] Payment to Follow <br />County of Allen , ss� <br />being duly sworn states that hie is the Treasurer <br />Shambaugh & Son LP having contracted with City of South Bead Dept of Pub to furnish certain <br />materials and or labor as follows Replace Fire Pump & BFP <br />for the project known as Replace Fire Pump & BFP <br />located at 120 Dr. Martin Luther King Jr. Dr S and owned by <br />and does hereby further state on behalf of the aforementioned suibcointractor/supplier: <br />(PARTIAL WAIVER) that there is due from the contractor the sum of <br />on] <br />Dollars <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 Waiver of <br />Lien which is given solely with, respect to said amount, and which waiver shall be effective only upon rec <br />of payment thereof by the undersigned; <br />(FINAL WAIVER) that there is dine from the contractor the sum of 15,0161.60 Dollars <br />[ ] receipt of which is hereby acknowledged: or <br />[he payment of which has been promised as the sole consideration of 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 of claim <br />whatsoever on the above -described property and Improvements thereon on account of LABOR or material or <br />both, furnished by the undersigned thereto, subject to limitations or conditions expressed herein, if any; and <br />further certifies that no other party has any cliam or right to, a lien on -;eoUht of any work performed or material <br />furnished" to the undersigned for said project, and e sco f !0ii idavit and waiver. <br />By Treasurer <br />Shambau_qh & Son LP z 7 -111, — <br />Fran i D. Feichter <br />WITNESS MiY HAND AND NOTARIAL SEAL, this 19, da/10 ul <br />My Commission Expires 09/20/2020 Katheii 51affldlft)�en <br />gy P <br />V.......... <br />Residing in Allen County S. <br />KATHERIN <br />ELAINE <br />Owner: 1 HANSEN <br />EXPI <br />.-.19/20/20 <br />OFt,1041111144111140 <br />