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Final Waiver of Lien <br />State of Indiana, County of� SS: <br />a7t('an <br />(Name of C being duty sworn that he/she is the re P1 Wert M <br />Officer) (Title) <br />Of " t? F1ee-+6C4 Lc having contracted with City of South Bend <br />(Contractor) (pwner) <br />to furnish certain materials and/or labor as follows; — eC <br />description) <br />for a project known as _.S /5-9' sonProject)e tr " l <br />q (N <br />located at%�SP °irrSd ►� 0 nth ��n <br />and owned by -Ci!y of South Bend <br />(Owaaer) <br />and does herdby further state on the behalf ofthe aforementioned subcontmotor/supplier: <br />(PARTIAL WAIVER) that there is due from the Contractor the sum of <br />Dollars^� <br />❑ receipt of which is hereby ackmowledged; or <br />❑ the payment of which has been promised as the sole consideration for this Affidavit and Final Waives~ of lien which is given <br />solely with respect to said amonaat$ and which walver shall be effective only upon receipt ofpayment thereof by this <br />undersigned; <br />CALWA114E11)tlaatthe.t ��c�✓ear <br />❑ receipt ofwhich is hereby acknowledged; or <br />® the Paya°nent Of which has been promised as the sole consideration forthis Affidavit and Final Waiver of Lien which shall <br />become ofr"octive only capon receipt of such payment. <br />"I BEFORE, the undersigned waives and releases unto the Owner ofsaid promises, any and all liens or claims whatsoever <br />on the above -described property and improve ends thereon as account of labor or anaterial or bode, f4mished b the undersigned <br />thereto, subject to limitations or conditions expressed herein„ if any; and farther certified that no other party has tiny claim. or right to it <br />lion on account of any work performed or material famished to the undersigned for said project, t; and wvithlra the scope of"this Ai"fialavlt <br />and WaiverofLlen. <br />rlt LC <br />vu01—M <br />STATE OF INDIANA " z „"" 1 sa uawa a c rzv a�uaa ) <br />St. �'Sltli i�ral�tlf"y <br />Corraiil Expires SS: <br />ST. JOSM"H COUNTY ) DecembOr 28, 2024 <br />,before me, the undersigned, a Notary Public, in and. for said Coaan an ly appeared 'l <br />and acknowledged the execution of the foregoing Affidavit anti Waivtar ofLien. <br />IN WITNESS WHMOF, I have hereunto suiasa rl ed my aaaane and aaaed my ofitciai seal on the � day of <br />.� <br />I*lotaray bi c Signature <br />My Commission Expires: <br />.m <br />Residing in Notary Pubiie l+lanwe <br />