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ISA Form as 1-402 <br />PREPARE IN DUPLICATE <br />Orlpinal - Contractor <br />Dupllcate - SubcontrectorlSuppller <br />AFFIDAVIT AND WAIVER OF LIEN <br />(X Final ❑ Partial ® Payment to Follow. <br />State of Indiana, County of St. Joseph , SS <br />Randall H. Rice _ being duly sworn states that he is the Asst. Secretary of <br />(Name of Officer) (Title) <br />Gibson -Lewis, LLC having contracted with City of So. Bend Brd of Pubiic Works to furnish certain <br />(Subcontractor: Supplier) IContractorl <br />materials and/or labor as follows General Construction <br />for a project known as IDet�rhar?els Black Center Renovations <br />located at _,,, South Bend, IN _ and owned by City of So. Bend Brd of Public Works <br />IOwner) <br />and does hereby further state on behalf of the aforementioned subcontractorlsupplier: <br />G1�XIC�CAA�)6AItX?QbE�Kf XIIdX�CDCtY,�C�fldb(�DdD�ttilC9i�(�C9h��JIQDCDCfliXX <br />_....�m_ _....m Dollars ($ <br />[ ] reoeipt of which is hereby acknowledged; or <br />l I the payment of which has been promised as the sole consideration of this Affidavit and Partial Waiver of <br />Lien which is given solely with respect to said amount, and which waiver shall be effective only upon receipt <br />of payment thereof by the undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor is the sum of <br />One Hundred Ninety Eight Thousand Six Hundred Seventy Three Dollars and 00/100Dollars ($ 198,673.00 <br />[ ] receipt of which is hereby acknowledged; or <br />[X I the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of <br />Lien 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 <br />on the above -described property and improvements thereon on account of LABOR or material or both, furnished by the <br />undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certifies that no other party <br />has any claim or right to a lien on account of any work perf or material furnished to the undersigned for said project, <br />and within the scope of this affidavit and waiver. Ild <br />Gibson-Lewis LLC Asst. Secreta <br />, <br />_..�..__ .......-_.. �.. �.,�.,��...�....� By _�...-..__�...:.� __...�� ...... Title ry <br />a <br />1 Firml lAuthorized Representative) <br />WITNESS MY HAND AND NOTARIAL SEAL, this <br />31 st d of January 2019 <br />3s...�_ <br />(Notarypublic) <br />My Commission Expires ... July 10, 2024 Printed <br />Residing in _ . St. Jose h County <br />9 1974 INDIANA SUBCONTRACTORS ASSOCIATION, INCORPORATED <br />Unauthorized Reproduction Prohibited <br />Elizabeth A. Biddle <br />ELIZABETH A. BIDDLE <br />Notary Public, State of Indiana <br />;SEAL r :� <br />St. Joseph County <br />My Commission Expires <br />NnI r <br />July 10, 2024 <br />10,87 <br />