PCA - 2023 Residential Demolitions - Proj No 123-068 - Ritschard Bros

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State of Indiana, County of St. Joseph SS: Rachelle L. Dolniak being duly sworn that he/she Is the President (Name of Officer) � (Title) Of Ritschard Bros., Inc. having contracted with City of South Bend (Contractor) (Owner) to fhmish certain materials and/or labor as follows; Demolition �— — - (Description) for a project known as _ 2023 Residential Demos (Name of Project) located at Various Addresses and owned by City of South Bend (Owner) and does hereby further state on the behalf of the aforementioned subcontractor/supplier: (PARTIAL WAMR) that there is due from the Contractor the sum of Dollars ❑ receipt of which is hereby aclntowledged; or ❑ the payment of which lies been promised as the sole consideration for this Affidavit and Final Waiver of Lienwhich is given solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the undersigned; (FINAL WAIVER) that the final balanco due &am the contractor is the sum of Sixteen Thousand Eight Hundred Seventy—four and 70/100-- ($16,874.70) ❑ receipt of which is hereby admowledged; or ® thepayment of which has been promised as the sole consideration for tluls Affidavit and Final Waiver of LIen which shall become offeetive only upon receipt of such payment. TI3SREFORE, the undersigned waives and releases unto the Owner of said premises, any and all liens or claims whatsoever on the above-descrlbed property and improvements thereon an account of labor or material or both, finished b the undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certified that no other party has any claim or right to a lien on account of any work performed or material furnished to the unders ed for said project, and within the scope of this Almdavlt and Waiver of Lien. Ritschard Bros., Inc. By (Firm) (AuthorizedRepresentative) STATE OF INDIANA ) SS: ST. JOSEPH COUNTY Before me, the undersigned a Notary Public, In and for said County and State, personally appeared Rachelle L . Dolniak and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, Ilave hereunto subscribed my name and affixed my official seal on the 19 th day of , eptldtd202 4 I G •.• Noitry Public Signature My Commission Expires: 2/ 2 / 0 -VAR ZO Michaela Ritschard Residing in St. Josepho ty, India _ Notary PubIicName ��'�� OF