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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of jl„SS: <br />b Jug duly sworn that he/she is the Rq n er, L nilgel- <br />e <br />(Maine of Officer) <br />Of Ind,having contracted with S:LtYQL�91W14,I nd i, a n a <br />—9N(Subcontractor/Suppla) - <br />to furnish certain materials and/or labor as follows: _,. Chenjj,1-_ jnd !L _parts <br />(Description) <br />for a project known as FCI 0 -,P.rod u tj <br />(Nanw, of Pr(Iject)" <br />located at Edison Park Well Field <br />and owned by City of South Bend n <br />. . .... I diana., <br />and does hereby further state on the behalf of the aforeniantioned subcontractor/supplier: <br />(PAT01AL WAIVER) that there is due from the Contractor the sum of <br />Dollars <br />El receipt of which is hereby acknowledged; or <br />'El the payinent of"which has been promised as the sole considerrjtlditfof ilu's AffdWt Md Final Va'iVel° oftlen wfii h is given <br />solely with respect to said atuolirif and. which wai f , it 'I <br />undersigned; p yMentfj,jerqofby,tho <br />(FINAL WAIVER) that the final balance due from the contractor is the sum <br />Of Si Xty-Three Thousand One Hundred Forty <br />J receipt of which is hereby acknowledged; or <br />fbe payniont ofvd-dcli liras been promisod asibe sole consideration for this Affidavit and Final Waiver of Lion which shall <br />beconio effective only ulwil rcccjp[ of SLIC1,1 fraylnent. <br />(TIEREFOIZE2 the iindersigned' wahros and releases iinto tho Own or of sa d all flons oi- clah s whatsoover <br />0eraiot ld my an 971 <br />,11 theerr <br />1,11prett), Suillect to lixkdlaflo)'Is oton(litions if oliy;' rnfd fal-11101° cedl thatno'0111or J)arly has flay claial'', "j, <br />lien, on acobuiit of 4,Iny 1voi-jr, 0'r matella) ight to a <br />&I-hished to <br />f,oi(lvV' give)"Of'LiCiL Id Withil" 1110 4"opo of this Affldayft <br />Peerless -Midwest Inc <br />-7 <br />By <br />at <br />STATE OF -NDIANA IV <br />I <br />Ss' <br />ST. JOSEPH COUNTY <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally jippeared James R. Williams <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITNESS VA-11PMOF I have hereunto subscribed iny name and affixed my offici seal on <br />ch 0 day of <br />seal <br />206 19 <br />CATHY S. LANCE <br />"p, <br />Notary Public, State of Indiana I No, a,' q I U <br />wt 111rc <br />'yeri St. Joseph county <br />My Commission Expires: , :4F <br />My Commission Expires <br />Cathy S. Lance <br />Residing in Indiana county, ­K­6'Fary paablrc . . . ....... 0 — so <br />