Laserfiche WebLink
Final Waiver of Lien <br />State of Indiana, County SS: <br />of <br />being duly sworn that he/she is the l �! ��i11 (Title) <br />(Name of Officer) <br />of S �tr'ctor��� <br />Cit of South Bend <br />�having contracted with Y (Owner ) <br />( 0 <br />to furnish certain materials and/or labor as follows: <br />(Description) <br />for a project known as <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 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 shalt 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 00 O O <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 furnished to the undersigned for said et, and within the scope of this Affidavit <br />and Waiver of Lien. <br />S)i 615 &VA 6i5T3 ,Ul- By 6 TANNER LEIBUVITZ <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 acknowledged the execution of the foregoing Affidavit and Waiver of Lien. <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my o clal seal on the 3 day of <br />Apo; ) L_ 202� LL" <br />Notary Public Signature <br />My Commission Expires: tyr,2 Lk <br />Residing in County, "Utanskillotary Public Name <br />o ry dianaCom73 <br />