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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of S t . Joseph SS: <br />Rachelle L. Dolniak being duly sworn that he/she is the President <br />(Name of Officer) (Title) <br />of Ritschard Bros., Inc. having contracted with City of South Bend <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: Commercial Drive Relocation <br />(Description) <br />for a project known as West Side Quiet Zone — Commercial Drive Relocation <br />(Name of Project) <br />located at 1522 Ford Street, South Bend, IN <br />and owned by Citv of South Bend <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 />Fifty—four Thousand Two Hundred Fifty—eight Dollars ($54,25B.00 ) <br />❑ receipt of which is hereby acknowledged; or <br />❑X 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, furnished 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 fumis}ted to the unders' ed for said project, and within the scope of this Affidavit <br />and Waiver of Lien. <br />Ritschard Bros., Inc. 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 C�gtxlfiyfti8�&tgtf, personally appeared Rachelle L. Dolniak <br />and acknowledged the execution of the foregoing Affidavit and Wai*,�`r� c ROs <br />IN WITNESS WHEREOF, I have hereunto subscribed M: � and affixtd1i_ p 4fficial seal on the 16 th day of <br />October AR)• ,,,j,�� � G��t✓��ui►� <br />AUB0G N`aryPublic Signature <br />•'_� <br />My Commission Expires: 2 / 27 / 28"� <br />Ritschard <br />Residing in St. Joseph County, Indiana //'����� i3Oi F %, �`\` Notary Public Name <br />