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Final Waiver of Lien <br />State of Indiana, County of �� ��� SS: <br />Tonn �i- LeA boyi It- being duly sworn that he/she is the {•�j)Q,Q�� <br />(Name of Officer) (Title) <br />of 1 IS 0,nd�' having contracted with City of South Bend <br />( ontractor) J (Owner) <br />to furnish certain materials and/or labor as follows: <br />(Description) <br />for a project known as <br />(Name of Project) <br />located at <br />and owned by City 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 acIozowledged; 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 />❑ 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 party has any claim or right to a <br />lien on account of any work performed or material famished to the undersigned for said project and within the scope of this Affidavit <br />and Waiver of Lien. <br />I I 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 <br />and aclaiowledged the execution of the foregoing Affidavit and Waiver of Lien. v <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official sea] on the t day of <br />202'� <br />Notary Public Signature <br />Debra A Urbansro <br />My Commission Expires: Notary Public <br />1\ 1 t <br />t.JosephCounhs <br />ission # NP0732273Notary Public Name <br />Residing inLZ4ssion E <br />