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Final Waiver of Lien <br />%" no\ S <br />State ofipdiaus-, County of SS: <br />being oftloer O �anqmf � ���: g duly sworn chat he/she is the <br />i��� <br />(Title) <br />ofYw t1 ,having contracted with City of South Bend <br />(Contractor) w (Owner) <br />to famish certain materials and/or labor as follows: <br />for a project known as <br />(Name of Project) <br />located at <br />and owned by City of South Bend y661, <br />(owner) <br />and does hereby further state on the behalf of the aforementioned subcontractor/supplier: <br />(PARTIAL WAIVER) that there is due from the Contractor the sum of <br />Dollars($ ) <br />❑ receipt of which is hereby acluiowledged; or <br />❑ the payment of which has been promised as the sole consideratioo 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 />� INAL WAIVER), It that the final! Mactce due om the con e ) tractor is ilia sum of <br />❑ receipt of which is hereby acknowledged; or <br />® thepaymeat 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 oivnor ofsaid promises, any and all liens or claims whatsoever <br />on the above -described property and improvements thereon mL account of labor or material or both, f ivnished b the undersigned. <br />thereto, snbject to limitations or conditions expressed herein:, if any, and flu llyer certified that no other party has any claim or right to a <br />lion on account of any work performed or material fin fished to the undersigned for sold pro, jectp and within the :scope of this Affidavit <br />and WaiverofLieu. <br />By <br />(Firm) \ <br />M <br />A (Authorized lteprescntative) <br />��,,el,5 ) <br />SS: <br />COUN I"Y <br />Before me, the undersigned, a Notary Public, In and for said County and State, personally appeared <br />X O <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITNESS WHEREOF, Ihave hereunto subscribed my name and affixed my, official seal on the day of <br />11 S <br />otary P lie 1 atzu°o <br />My Commission Expires: <br />Residing in _l, County, <br />OFFICIAL SEAL <br />LUCY KONOVALCHIK <br />NOTARY PUBLIC - STATE OF ILLINOIS <br />W COMMISSION EXPWS 09116/23 <br />1 <br />