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AFFIDAVIT AND WAIVER OF LIEN <br />State of ^,iAraska, County Of Douglas SS: <br />Rory Sudbeck being duly sworn that he/she is the President <br />(Name of Officer) (Title) <br />of Viking Painting I.L.C_ _ having contracted with City of South Bend, IN <br />(Subcontractor/Supplier) (Owner____ <br />to furnish certain materials and/or labor as follows: Rehab Water Tank <br />for a project lalown as Northwest. Elevated Tank Rehablitation Project <br />(Name of Project) — - --- -- <br />located at City of South Bend, IN <br />and owned by City of South Bend, IN <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 (Owner) the sum of <br />Dollars <br />❑ receipt of which is hereby acknowledged; or <br />❑ the payment ofwhich has been promised as the sole considerations 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 there:af by the <br />undersigned; <br />(FINAL WAIVER) that the final balance due from the contractor is the sum of <br />Twenty Nine Thousand Five Hundred Fifty -Six Dollars and 00/100 0 9 556.Ot) ) <br />❑ receipt of which is hereby acknowledged; or <br />th- payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien WEcw shall <br />become effective only upon receipt of such payment. <br />T{iF'REFORE, the undersigned waives and releases unto the Owner of said premises, any and all liens or claims whatsoever <br />on the above-des;uibed property and improvements thereon an account of labor or material or both, furnished b the undersigned <br />thereto, sul jest to limfMiuns or conditions expressed herein, if airy; and further certified that no other party has any claim or right to a <br />Hen on account of any work performed; or material fumished to the undersigned for said project, and within the scope of this Affidavit <br />and Waive~.- ofiLiwo. <br />By <br />(Fir (Authorized Representative) 1",P-1- <br />STATE OF Nebraska ) SERENA L. STACH <br />SS: General Notary - State of Nebraska <br />g COUNTY . ) My Commission Expires Dec 20, 2023 <br />Douglas <br />#etcereme, the undersigned, allotan, Public, in a . forsaid Col:. it:, s ej State, personally appeared 5W(6cL <br />and aclmow lodged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITNESS WfEREOF, I have hereunto subscribed my name and affixed my official seal on the � day of <br />20915 <br />My Commmir -,'on Expires: <br />Residing in _ a�rl2'��l �� County, „�� Notary Public Name <br />