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FFIDAVIT AND WAIVER OF LIEN <br />State of Indiana County Elkhart <br />rt SS: <br />ww_ <br />Marital Kreps __m.. being duly sworn that he/she is the Vice -President _ <br />(Name of Officer) (Title) <br />of Brown & Brown General Contractors, InRaving contracted with <br />­�Subcontr4ictor/Supplier;) <br />to furnish certain materials and/or labor as follows: Handrails <br />for a project known as <br />located at <br />and owned by <br />Bendix Theater <br />Century Center <br />City of South Bend, IN <br />City of South Bend, IN <br />(Description) <br />(Name of Project) <br />(Owner) <br />and does hereby fiuther state on the behalf of the aforementioned subcontractor/supplier: <br />(PARTIAL WAIVER) that there is due from the Contractor the sum of <br />(Contractor) <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 />Twelve thousand nine hundred fl�"teen and/1�b� um of <br />ITM�.. IT o ontractor is the s �2 915.00 <br />AL WAIVER) that the final ba ce due f <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, furnished b the undersigned <br />thereto, subject to limitations or conditions expressed herein, if any; mid further certified thatno other party has any claim or right to a <br />lien on account of any work perforated or material rurnished to the undersigned for said project, and within the scope of this Affidavit <br />and Waiver of Lien. <br />r <br />n eneraontractors, Inc." <br />Brown & Brown General CBy <br />(Firm) I-L4e�(q—At, <br />.. llepresentative).aa.� <br />STATE OF INDIANA ) <br />) SS: <br />=*080W,9Xq)" Elkhart ) <br />Before me, the undersigned„ a, Notary Public, in and for said County and State, personally appeared Marita Kreps <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN <br />-... day of <br />Janua 200y affixed my official seal on the 15tht <br />WITNESS WHEREOF, I have hereunto subscribed m naameme and <br />Notary Public Sgnature <br />My Commission Expires: 4/3/2025 <br />.......................................... <br />Indiana ToddAMarek`Not: <br />Residing in shall _ 1 County, �, <br />Marshall <br />.., . o. _.„...._,�..�gotary Public <br />SEAL <br />Marshall County, State of Indiana <br />My Commission Expires April 3, 2025 <br />C�)mrnfsslan Number, 698752 <br />Marek <br />ME <br />