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Final Waiver of Lien <br />State ofindiana, County of <br />SS. <br />�� �� / ✓ ' being duly sworn that he/sue is the <br />(Nam ofOfipoer) (Title) <br />of having contracted with City of South Bend <br />(Contractor) (Owner) <br />to Aimish certain materials andlor labor as follows: <br />for a project known as r- S <br />(dame o 'raft) <br />located at <br />and owned by <br />of South Bend <br />and does hereby further state on the behalf of the aforementioned subcontraotordsuppller. <br />(PARTIAL WAIVER) that there is due from the Contractor 1ho. am of <br />Dollars . <br />❑ receipt of which is hereby aftow Bilged; or <br />❑ the payment of which loves boon, 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 bo e e only upon receipt ofpayment 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 admowle ed; or <br />® the Payment ofwhi h bas been promised as the sole consideration for 96 Affidavit and Final Waiver of Lien which shall <br />become otTantive only upon receipt of such payrnent. <br />b` <br />THEREFORE, the undarsigned waives end releases unto the Omwer ofsaid promises, any and all liens or claims whatsoever <br />on the, above -described property and improvements thereon an account of labor or material or both, AuuishW b the undenWed <br />therato, subjeot to limitations or conditions expressed herain, if any; mid norther cartMed that no oilier party has any claim or right to a. <br />Ron; on amunt of any work performed or material A nrishod to the undersigned for said project, and within the scope of this Affidavit <br />and Walver ofLien. <br />C/, C <br />r01, t% <br />BY <br />(Firma)aRepresentative) <br />STATE OF IMIANA ) <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 s�cnowl � l��l a ared <br />edged the exec <br />ution of the foregoing Affidavit and Waiver of Lien. I <br />IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my o ' lal seal on the �� h day of <br />-� Z1.21.� <br />1+1C Pub. lc Y attn'e <br />My Commission Nt�T'1�itY PUBLIC 'STATE Of INDIANA <br />i"Imnc <br />ANNETTE FgRTHINGRoalding rn Co t, tISNY IIQN U oalublit <br />WSSION EXPRES JUNE 17, 2026 1 <br />