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AFFIDAVIT AND WAIVER OF LIEN <br />State of Indiana, County of St Joseph SS: <br />Jennifer Brown being duly sworn that he/she is the �f-ice President <br />(Name of Officer) (Title) <br />Of Martell Flecirjrl I I r having contracted with _City of South Bend <br />(Subcontractor/Supplier) (Contractor) <br />to furnish certain materials and/or labor as follows: �Irt4raL <br />(Description) <br />for a project known as 2016 Lamppost ost Program <br />(Name of Project) <br />located at <br />and owned by <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 />-Fourftiisarr&-7&1-00 4218.76 ) <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 waicriai furnished to the undersigned for said project, and within the scope of this Affidavit <br />and Waiver of Lien. <br />Martell €leGtrie1F66C---- -- By it <br />(Finn) 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 Jennifer Breverr <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 seal on the -R 157 day of <br />OC2tD PJf Q' — — 201(o <br />Notary Public Signature <br />My Commission Expires: ���® Z pZ -6 <br />Residing in %�_ SQ�N County, jQ Not Pb, me RENABALDWIN <br />u� <br />�' s •"'•' tl ovary Pu b'i C. State of Indiana <br />'oo�n9i'• '_ Si.:os,-oh Coumy <br />:a= <br />$EAR COO1 nL 6'.uL1 U GJJ)''C <br />M•. Convni r. n c-.64 <br />Uiws <br />",",°'„;o°' Eebruair 28, 2023 <br />