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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of S t . —Joseph SS: <br />attge W being duly sworn that he/she is the General Mana er <br />(Name of Officer) (Title) <br />of Peerless -Midwest Inc. mITITIT having contracted with C t of South Bend <br />(Subcontractor/Supplier) (Contractor) <br />to famish certain materials and/or labor as follows: Well C l <br />(Description) <br />for a project known as e . <br />(Name of Project) _. <br />located at <br />and owned by City of South Bend De artment of PublicPqblic lonk s <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 acknowledged; or <br />❑ the payment of which has been promised as the sole consideration 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 />(FINAL WAIVER) that the final balance due from the contractor is the sum of <br />Sixty -Two Thousadn Dollars & No Cents. C?�pQQ <br />❑ receipt of which is hereby acknowledged; or <br />ID the payment 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 Owner of said premises, any and all liens or claims whatsoever <br />on the above -described property and improvements thereon an account of labor or material or both, famished b the undersigned <br />thereto, subject to limitations or conditions expressed herein, if any; and further certified that no other party has any claim or right to a <br />lien on account of any work performed or material furnished to the undersigned for said project, and within the scope of this Affidavit <br />and Waiver of Lien. <br />Peerless -Midwest Inc. �� <br />By:. <br />(Firm) (Authorized Representative) <br />STATE OF INDIANA ) <br />SS: <br />ST. JOSEPH COUNTY ) <br />Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared James R . Williams <br />and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my office° 4seall,0yahe th day of <br />Februar 200 2QACATHY S. LANCE Not nS.t�t�yg <br />Notary Public state of Indiana <br />•�ncra�r <br />My Commission Expires"' St. Joseph county <br />,p�� Cathy S. Lance <br />'*�xJt$ 0 <br />Indiana <br />Residing in Notary Public Name <br />