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AFFIDAVIT AND WAIVER OF LIEN
<br />PROJECT NUMBER:
<br />State of INDIANA, County of S'T. JOSEPH ss:
<br />The undersigned, being first duly sworn, states, warrants and deposes, personally and as a duly authorized officer or
<br />representative of the Subcontractor as designated below (referred to herein as "Subcontractor") as follows:
<br />Dosicination of Instrument
<br />This is a: ❑X Partial (Affidavit & Waiver of Claims) ®Final (Affidavit & Waiver of Claims)
<br />And is: [Conditional (Payment To Follow) ❑Unconditional (Payment Received)
<br />HUMER
<br />M 0 0
<br />Subcontractor Name: FUER'BRINGER LANDSCAPING AND DESIGN INC.
<br />Subcontractor Address: 22.53Q BRICK a AD — SOUTH BEND INDIANA 46628
<br />Name of Person Signing: DANIEL R. FUERBRINGER Title: PRESIDENT/OWNE R
<br />Project (Name): Lot 12 US 31 Industrial Park
<br />Project Location/Address:
<br />Contractor:
<br />Owner: City of South Bend Board of Public Works
<br />Payment Amount: Two Thousand Six Hundred Five Dollars nd 50M00, 2 605. 0
<br />Payable through the period ending (date): May 13, 2019 (referred to herein as the "Effective Date")
<br />The Terms of This Instrument Are:
<br />f. Subcontractor has contracted with Contractor to furnish labor, materials, equipment and/or services in furtherance of Contractor's
<br />contractual obligations for the described project.
<br />2. If this instrument is designated as a Partial Affidavit and Waiver, the Payment. Annount recited above is the; current balance due the
<br />Subcontractor, and such amount, together with any and all previous payments received by Subcontractor, is the total sum due to
<br />Subcontractor, exclusive of contractually, provided retainage, for all labor„ materials„ equipment or services furnished by or through
<br />Subcontractor to or for the Contractor in respect of the Project through the above stated Effective Date, if this instrument is designated
<br />a Final Affidavit and Waiver, the Payment Amount is the full and final amount due the Subcontractor for any and ail labor, materials,
<br />equipment or services furnished or to be furnished by or through the Subcontractor for the Project.
<br />3. The listing on the attached Application For Payment form is incorporated hereon by reference and sans forth, fully and correctly, the
<br />names of sub -subcontractors, materialmen, equipment lessors and laborers engaged by or under the ernvp, cy of subcontractor and to
<br />whom monies are presently due and owing from Subcontractor for labor, materials, equipment or services iLar°jj shed to or for the Project.
<br />Except as otherwise specifically stated in such listing in sub -subcontractors, materialmen and laborar i engaged or employed by
<br />Subcontractor have been paid in full for all labor, materials, equipment or services furnished In respect of Um projecL
<br />4. In consideration of payment of the Payment Amount, the Subcontractor completely waives, discharges and releases the Contractor, any
<br />and all owners of any title or interest in the real estate upon which the project is situated, wwl their respmu ctive sureties, successors
<br />assigns„ from all liens and claims whatsoever in respect of or arising from any and all labor„ rnaiarlals, eqUl3rrierat or services furnished
<br />by or through Subcontractor to or for the Project„ including without limitation mechanics, liens and clainas against any contract
<br />proceeds. If this instrument is designated as a Partial Affidavit and Waiver, the waiver„ discharge and release paovidad by this paragraph
<br />shall, apply only to labor, materials, equipment or services furnished on or before the Effeciiva Date haraof. if this instrument is
<br />designated as a Final Affidavit and Waiver, the waiver, discharge and release provided by this paragraph shall notwithstanding the
<br />Effective [date of this Instrument.
<br />5. The undersigned and Subcontractor will indemnify Contractor and hold it harmless again any loss, cos, or expemse, including cost of
<br />bond premiums, litigation expenses and attorney fees„ for and in respect of any breach of any r,cvarmlt, fePrr sentation or warranty
<br />contained herein or any lien or other claim asserted by any person in respect of labor, materials, egLJ pWn:at�� or ser vices which are within
<br />the scope of this instrument.
<br />6. If this instrument is Conditional, the terms eof shall ecome effective upon paymer of -the Payment Amount to Subcontractor, or at
<br />Contractor's option, jointly to Subcontra r and any pe , ons identified and in r cuve amounts as stated on the attached Application
<br />For Payment form, which payment sh the sole consi oration of this Aff' it and Waiver. If this instrument is designated above as
<br />Unconditional, the undersigned and S contractor ack owl2recei of the Payment Amount and agree that this instrument shall be
<br />effective in all respects as of the dat ereof. m.�...,
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<br />Subcontractor's Signature.
<br />Subscribed and Sworn to befor,, me this 13 day of lay 2019,
<br />Notary Public Signature: � �� � � � My Commission Expires: Le _�66 2024
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