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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of <br />ViCKI SHEPARD <br />(Name of Officer) <br />ST. jOSEPH <br />of CARPET SERVICE OUTLET INC <br />(Subcontractor/Supplier) <br />to furnish certain materials and/or labor as follows: <br />being duly sworn that he/she is the <br />SS: <br />PRESIDENT <br />(Title) <br />having contracted with CITY OF SOUTH BEND <br />CARPET AND INSTALLATION <br />(Description) <br />for a project known as MORRIS PERFORMING ARTS <br />(Name of Project) <br />located at 211 NO. MICHIGAN STREET SOUTH BEND INDIANA <br />and owned by CITY OF SOUTH BEND <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 />(Contractor) <br />the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Caen 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 TEfNR) Icontractor is the sum ofINTM9_AN FDKY Me" <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 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 panty 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 (his Affidavit <br />and Waiver of Lien. <br />CARPET SERVICE OUTLET INC By(Fir <br />(Author' d Representative) <br />STATE OF INDIANA ) Y <br />olandaGiles <br />Notary Sealate of fn�iana <br />SS; unty <br />ST. JOSEPH COUNTY ) Commiap6s93i4Before me, the undersigned, a NO 1, Cs ip 15416 9 rr <br />fate, personally appeared � L-L <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 official sea o 1 day of <br />200 _AA <br />Notary ublic Sn a e <br />My Commission Expires: <br />Residing in V County, ��� �- Ct No Public Name <br />