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® Final <br />State of Indiana, County of St. Joseph, SS <br />Randall H. Rice <br />ISA Form #1 - 402 <br />PREPARE IN CUPLICATE <br />Original - Contractor <br />AFFIDAVIT AND WAIVER OF LIEN Duplicate - Subcontrator <br />❑ Partial ® Payment to Follow <br />being duly sworn states that (s)he is the Asst. Secretary of <br />(Name of Officer) (rille) <br />Gibson -Lewis, LLC having contracted with CITY OF SO. BEND BRD OF PUBLIC to furnish certain <br />(Subconlraclor/Supplier) (Contractor) <br />materials and/or labor as follows General Construction <br />( escription <br />for a project known as SB PARKING GARAGE IMPROVEMENTS <br />located at SOUTH BEND, IN and owned by <br />and does hereby further state on behalf of the aforementioned subcontractor/supplier: <br />6akfmti�Slf�CAz1 ' a4t tttfl�s a <br />[ ] receipt of which is hereby acknowledged; or <br />CITY OF SOUTH BEND <br />Dollars ( <br />(Owner) <br />[ ] the payment of which has been promised as the sole consideration of this Affidavit and Partial Waiver of <br />Lien which is given soley with respect to said amount, and which waiver shall be effective only upon <br />receipt of payment thereof by the undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor is the sum of <br />One hundred twenty-two thousand eight hundred sixty-eight and 47 / 100 Dollars ( $ 122,868.47 ) <br />[ ] receipt of which is hereby acknowledged; or <br />[ X] the payment of which has been promised as the sole consideration of this Affidavit and Final Waiver of Lien <br />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 on <br />the above -described property and improvements there on on account of LABOR or material or both, furnished by the <br />undersigned thereto, subject to limitations or conditions rases herein, if any; and furthre certifies that no other party has <br />any claim or right to a lien on account of any work rfo tried or terb P tturn ed to the undersigned for said project, and <br />within the scope of this affidavit and waiver. <br />Gibson -Lewis, LLC By Title Asst. Secretary <br />(Authorized Representative) <br />WITNESS MY HAND AND NOTARIAL SEAL, this 10th day of January 2019 <br />.I <br />(Notary Public) <br />My Commission Expires: July 10, 2024 Printed Elizabeth A. Biddle <br />Residing in St. Joseph County <br />„"„;`" ELIZABETH A. BINDLE' <br />41 <br />Notary Public, State of Indiana <br />SEAL L' :. St. Joseph County <br />r i.•�t My Commission of <br />f ......... July 10, 2024 <br />