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HomeMy WebLinkAboutSmock - $34,563Disbursements of Loan Proceeds from the Borrower Loan Account to (or for the account of) Borrower in the amount of the "Total Authorized Disbursement" line in the "Amount of Authorized Disbursement" column (see form of notice below) shall be made in accordance with the terms and conditions of. the Agreement, the other Loan Documents, and the Disbursement Instructions promptly upon receipt by Lender of a notice in the following form signed by the President, Vice President, Secretary, or Executive Director of CRC: Mercantile Bank hereby is instructed to make a disbursement of Loan Proceeds from the Borrower Loan Account to (or for the account of) Borrower in: (a) the amount of the "Total Authorized Disbursement: line in the "Amount of Authorized Disbursement" column below: and (b) accordance with the terms and conditions of the Agreement, the other Loan Documents, and the Disbursement instructions. Purpose of Authorized Disbursement Amount of Authorized Disbursement Amount to be paid by Village Financial, LLC as per the Hanover Square Improvements installment purchase contract Application 7 (Smock) October 2011 $ 1,413.00 Application 8 (Smock) December 2011 $ 33,150.00 Total Authorized Disbursement $ 34,563.00 All terms used in these Disbursement Instructions without definition shall have the meanings ascribed thereto in that certain Loan Agreement (Hanover Square Improvements), dated May , 2011, by .nd between Lender and Village Financial, LLC. Dated: 10 Z/ Z CITY OF CARMEL REDEVELOPMENT COMMISSION Printed Title Les S. Olds Executive Director It is acknowledged and agreed by the parties that CRC has reserved the right to require, as a condition of authorizing disbursement of Loan Proceeds from the Borrower Loan Account to (or for the account of) Borrower: (a) completion of satisfactory inspection by CRC of the portions of the Hanover Square Improvements to which the disbursement relates; and (b) receipt of customary submittals. Application 1 Application 2 Application 3 Application 4 Application 5 Application 6 Application 7 Application 8 Hanover Square Improvements (Smock) April 2011 Paid by Village Financial, LLC $ 85,007.92 June 2011 Paid by Village Financial, LLC $ 91,047.83 July 2011 Paid by Village Financial, LLC $ 67,792.72 August 2011 Paid by Village Financial, LLC $ 19,481.85 September 2011 Paid by Village Financial, LLC $ 18,054.68 October 2011 Paid by Village Financial, LLC $ 15,552.00 November 2011 Amount to be paid by Village Financial, LLC $ 1,413.00 December 2011 Amount to be paid by Village Financial, LLC $ 33,150.00 CONTRACTOR Smock Fansler Applications # 7 EQUIPMENT Fountain Equipment Piping /Pump /Installation /Elec Garage Improvements Paving and Surface Equipment PAC HANOVER SQUARE IMPROVEMENTS - $341,305.61 (MISC- 800064) PAYMENT SUMMARY 1 Original Contract Amount $ 331,500.00 2 Net Change by Change Order $ - 3 Contract Sum to Date $ 331,500.00 4 Total Completed & Stored to Date $ 331,500.00 5a Retainage of Completed Work $ 33,150.00 5b Retainage of Stored Materials $ - 5t Total Retainage $ 33,150.00 6 Total Earned Less Retainage $ 298,350.00 7 Previous Payment $ 296,937.00 8 Current Payment Due $ 1,413.00 8a Current Payment Due - CRC $ - 8t Total Owed to Contractor $ 1,413.00 9 Balance To Finish, Including Retainage $ 33,150.00 (Column F, Below) (Column H, Below) (Line 4 - Line 5t) CONTRACT TOTAL $ 181,785.00 $ $ 71,215.00 $ $ 23,500.00 $ $ 55,000.00 $ PREVIOUSLY COMPLETED 181, 785.00 71, 215.00 23,030.00 53,900.00 COMPLETED STORED COMPLETED REMAINING RETAINAGE THIS PERIOD MATERIALS TO DATE BALANCE Inc Retainage $ - $ $ 181,785.00 $ 18,178.50 $ 18,178.50 $ - $ - $ 71,215.00 $ 7,121.50 $ 7,121.50 $ 470.00 $ $ 23,500.00 $ 2,350.00 $ 2,350.00 $ 1,100.00 $ $ 55,000.00 $ 5,500.00 $ 5,500.00 $ 331,500.00 $ 329,930.00 $ 1,570.00 $ $ 331,500.00 $ 33,150.00 $ 33,15n 00 AIA Type Document Application and Certification for Payment Page 1 of 2 TO (OWNER): VILLAGE FINANCIAL LLC 770 3RD AVENUE SW CARMEL, IN 46032 FROM (CONTRACTOR): Smock Fansler Corporation 2910 W. Minnesota Street Indianapolis, IN 46241 CONTRACT FOR: PROJECT: HANOVER SQ FOUNT @ CITY CTR. 770 3RD AVENUE SW CARMEL. IN 46032 VIA (ARCHITECT): APPLICATION NO: 7 7 PERIOD TO:11/30/2011 ARCHITECT'S PROJECT NO: CONTRACT DATE: DISTRIBUTION TO: _ OWNER ARCHITECT CONTRACTOR CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for Payment, as shown below, in connection with the Contract. Continuation Sheet, AIA Type Document is attached. 1. ORIGINAL CONTRACT SUM $ 2. Net Change by Change Orders $ 3. CONTRACT SUM TO DATE (Line 1 + 2) $ 331,500.00 0.00 331,500.00 4. TOTAL COMPLETED AND STORED TO DATE $ 331,500.00 5. RETAINAGE: a. 10.00 % of Completed Work /do The Undersigned Contractor certifies that to the best of the Contractor's knowledge, information ar-' belief the work covered by this application for Payment has been completed in accordance wilt Contract Documents, that all amounts have been paid by the Contractor for Work for which prevlo.._ Certificates for Payment were issued and payments received from the owner, and that current payment shown herein is now due. P YmttP(ItLISL /CG'ii /�o CONTRACTOR: Smock Fansler Corporation 2910 W. Minnesota Street Indianapolis, IN 46241 By: T.M. FANSLER / CEO State of IN %, _ 33,150.00 ARC HITECT'�I County of: MORGAN \ cer �Vn- \`b° Subscribed and Swo/rrnnJtc ) IL 33,150.00 Notary Public; LUI / vSs f/ S 70 My Commission Expires, � 1n Accordance with the CI > / 3 - °6T prising the above appiica ects knowledge, Information a work is in accordance with they of the AMOUNT CERTIFIED. t00% x1-4 • �aa �� b. 0.00 % of Stored Material $ 0.00 Total retainage (Line 5a + 5b) 6. TOTAL EARNED LESS RETAINAGE (Line 4 Tess Line 5 Total) 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT (Line 6 from prior Certificate) $ 8. CURRENT PAYMENT DUE 298,350.00 296,937.00 1,413.00 9. BALANCE TO FINISH, INCLUDING RETAINAGE (Line 3 less Line 6) $ 33,150.00 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Total changes approved in previous months by Owner 0.00 0.00 Total approved this Month 0.00 0.00 TOTALS 0.00 0.00 NET CHANGES by Change Order 0.00 AMOUNT CERTIFIED.. (Attach explanation ff ern Application and o ke C ARCHITECT' \. By: this filed) This Cerh'cate is •t ne, , ._ _ __ ...actor named he in. Is •ance Payment and acceptance of payment are without prejudice to any rights of the • wner or Contractor under this Contract. AIA Type Document Application and Certification for Payment Page 2 of 2 TO (OWNER): VILLAGE FINANCIAL LLC 770 3RD AVENUE SW CARMEL, IN 46032 FROM (CONTRACTOR): Smock Fansler Corporation 2910 W. Minnesota Street Indianapolis, IN 46241 CONTRACT FOR: PROJECT: HANOVER SQ FOUNT @ CITY CTR. 770 3RD AVENUE SW CARMEL, IN 46032 VIA (ARCHITECT): APPLICATION NO: 7 PERIOD TO:11/30/2011 ARCHITECT'S PROJECT NO: CONTRACT DATE: DISTRIBUTION TO: _ OWNER _ ARCHITECT CONTRACTOR ITEM DESCRIPTION SCHEDULE PREVIOUS VALUE APPLICATIONS 1 2 3 4 FOUNTAIN EQUIPMENT PIPING /PUMP INSTALLATION /ELEC GARAGE IMPROVEMENTS PAVING AND SURFACE EQUIPMENT REPORT TOTALS 181, 785.00 71,215.00 23,500.00 55,000.00 COMPLETED THIS PERIOD STORED MATERIAL 181, 785.00 71,215.00 COMPLETED STORED % BALANCE RETAINAGE 0.00 0.00 181,785.00 100.00 0.00 18,178.50 0.00 0.00 71,215.00 100.00 23,030.00 470.00 0.00 23,500.00 100.00 53,900.00 1,100.00 0.00 55,000.00 100.00 0.00 7,121.50 0.00 2,350.00 0.00 5,500.00 $331,500.00 $329,930.00 $1,570.00 $0.00 $331,500.00 100.00 $0.00 $33,150.00 AFFIDAVIT AND WAIVER OF LIEN [ ] Final [X] Partial [X] Payment to Follow State of Indiana County of Marion T.M. Fansler , being duly sworn states that he is the CEO of SMOCK FANSLER CORP. having contracted with: Village Financial LLC to furnish certain labor, materials, and /or services as follows: Misc. Construction for a project known as: SFC #11 -023 Hanover Sq. Fountain ( Clay Ctr. located at Carmel, IN and does hereby state on behalf of the aforementioned contractor: (PARTIAL WAIVER) that there is due from the owner the sum of: ($1,413.00) One Thousand Four Hundred Thirteen Dollars and No /100 [ ] receipt of which is hereby acknowledged; or [X] the payment of which has been promised as the sole consideration of this Affidavit and Partial Waiver of Lien which 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 balance due from the owner is the sum of ($0.00) [ ] receipt of which is hereby acknowledged; or [ ] the payment of which has been promised as the sole consideration of this Affidavit and Final Waiver of Lien which shall become effective upon receipt of such payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all lien or claim whatsoever on the above - described property and improvements thereon on account of Labor, Materials, and/or Services, furnished by the undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certifies that no other party has any claim or right to a lien on account of any work performed, materials, or services furnished to the undersigned for said project, and within the scope of this affidavit and waiver. SMOCK FANSLER CORP. By WITNESS MY HAND AND NOTARIAL SEAL, this 18th day of November , 2011. r rt Melissa J. Bishop Notary/Public My commission expires November 30, 2016 Residing in Morgan County CEO 0\06M1111111:111:007// 14 .vRn:r,giuiG7i /, SEAL '1 q ? - , OF INS ' SUBCONTRACTOR'S SWORN STATEMENT OF INDEBTNESS & WAIVER OF LIEN STATE OF INDIANA COUNTY OF HAMILTON T.M. Fansler Being duly sworn upon his /her oath disposes and says that: 1. He /she is CEO (inserting sole proprietor, partner or corporate office held, as the case mayby), to Smock Fansler Corporation hereafter called the "Subcontractor". He /she is over the age of twenty one. He /she is authorized to make this affidavit on behalf of Subcontractor. 2. Subcontractor is the Fountain Subcontractor for the construction of the development known as Hanover Square Improvements located in Carmel (City), INDIANA (state), hereafter referred to as the "Development ", pursuant to the contract between the Subcontractor and Village Financial, LLC, the Owner. • 3. This affidavit is made for the express purpose of inducing Village Financial, LLC, to make payment to Subcontractor of the invoice submitted herewith for labor and materials furnished pursuant to said Contractor. Upon receipt of said payment the Subcontractor hereby waives any lien reights to which Subcontractor is entitled for labor or materials furnished for the development to the date hereof. 4. Subcontractor agrees that upon receipt of the payment amount described above, Subcontractor shall immediately execute in favor the Owner, the "Transfer of Title" document (attached as Exhibit A) for all labor and material furnished to the extent described above. 5. Listed below are all suppliers or other persons who either has furnished or might furnish the Subcontractor with materials, appliances, machinery, fixtures or furnishing placed upon or installed on the development. Mark (X) in the appropriate column for EACH supplier listed. Place an (X) in column: 1.) If a waiver of lien by supplier conditioned by payment of a specified amount is attached hereto. (In this case also show the amount owed the supplier). 2.) If a FULL (final) lien release has been signed and delivered to the General Contractor. 3.) If the initial delivery has not been made. Supplier List (Add list if necessary) Billed to Date Previously Paid Balance Automatic Irrigation & Supply $164.90 $164.90 $0.00 D Transport Inc. $520.00 $520.00 $0.00 Fastenal Company $16.49 $16.49 $0.00 Harrington Industrial Plastic $5,397.06 $5,397.06 $0.00 Irving Materials Inc. $8,328:00 $945.00 $7,383.00 Jobsite Supply $558.50 $558.50 $0.00 Service Pipe Supply $4,517.94 $3,161.65 $1,356.29 The Fountain People $181,785.00 $181,785.00 $0.00 Utterback Supply $169.46 $169.46 $0.00 White Cap Construction $127.00 $127.00 $0.00 Rogers & Co. of Indiana Inc. $82.95 $82.95 $0.00 HD Supply Waterworks.LTD $309.55 $309.55 $0.00 Noblesville Landfill Inc. $210.00 $210.00 $0.00 Architectural Brick & Tile Inc. $16,051.63 $0.00 $16,051.63 Allied Wholesale Electric $286.32 $286.32 $0.00 Santarossa Mosaic & Tile Co. $53,867.52 $0.00 $53,867.52 Maxim Electric LLC $10,000.00 $9,000.00 $1,000.00 # 1 and 2 correspond to the same numbered choices on the waiver format. Village Financial, LLC is hereby authorized to make payment to each such unpaid creditor either directly or by check jointly payable to Subcontractor and such creditor, as Village Financial, LLC shall determine. 5. There are no bills, charges, costs or expenses for labor or material which could now or hereafter result in lien being filed against the Development or a claim being asserted against the General Contractor except the persons or business named in Paragraph 4 above. IN WITNESS WHERE OF, affiant has signed this document on behalf of the Subcontractor this 18th day of November f , 2011. 1 T.M. Fansler CEO State of INDIANA County of MORGAN Subscribed and sworn to before me, a Notary Public in and for said County and State, this 16th day of November , 2011. My Commission Expires: November 30, 2016 Melissa J. Bishop (Print Name) Attachment A TRANSFER OF TITLE Smock Fansler Corporation (Contractor) transfers to Village Financial, LLC any and all right, title and /or interest that Contractor has in any Tabor and /or materials described in (i) that Affidavit of Waiver of Lien executed by the Contractor on November 18th 2011, and (ii) in the "Amount of this Request" section of that "CONTRACTOR" By: Printed: Title: T.M. Fansler CEO PAC HANOVER SQUARE IMPROVEMENTS - $341,305.61 (MISC- 800064) CONTRACTOR Smock Fansler Applications # 8 EQUIPMENT Fountain Equipment Piping /Pump /Installation /Elec Garage Improvements Paving and Surface Equipment PAYMENT SUMMARY 1 Original Contract Amdunt 2 Net Change by Change Order 3 Contract Sum to Date 4 Total Completed & Stored to Date 5a Retainage of Completed Work 5b Retainage of Stored Materials 5t Total Retainage 6 Total Earned Less Retainage 7 Previous Payment 8 Current Payment Due 8a Current Payment Due - CRC 8t Total Owed to Contractor 9 Balance To Finish, Including Retainage $ 331,500.00 $ - $ 331 ,500.00 $ 331,500.00 (Column F, Below) $ - (Column H, Below) $ - $ - $ 331,500.00 (Line 4 - Line 5t) $ 298,350.00 $ 33,150.00 $ - $ 33,150.00 $ - CONTRACT TOTAL PREVIOUSLY COMPLETED $ 181,785.00 $ $ 71,215.00 $ $ 23,500.00 $ $ 55,000.00 $ $ 331,500.00 $ COMPLETED THIS PERIOD 181, 785.00 71,215.00 23,500.00 55,000.00 331,500.00 $ STORED MATERIALS $ $ $ $ $ COMPLETED REMAINING RETAINAGE TO DATE BALANCE Inc Retainage $ 1 81,785.00 $ $ 71,215.00 $ $ 23,500.00 $ $ 55,000.00 $ $ 331,500.00 $ $ NA Type Document Application and Certification for Payment Page 1 of 2 TO (OWNER): VILLAGE FINANCIAL LLC 770 3RD AVENUE SW CARMEL, IN 46032 FROM (CONTRACTOR): Smock Fansler Corporation 2910 W. Minnesota Street Indianapolis, IN 46241 CONTRACT FOR: PROJECT: HANOVER SQ FOUNT @ CITY CTR. 770 3RD AVENUE SW CARMEL, IN 46032 ViA (ARCHITECT): APPLICATION NO: 8 PERIOD TO:12/31/2011 ARCHITECT'S PROJECT NO: CONTRACT DATE: DISTRIBUTION TO: _ OWNER _ ARCHITECT CONTRACTOR CONTRACTOR'S APPLICATION FOR PAYMENT ?pplication Is made for Payment, as shown below, In connection with the Contract 'Continuation Sheet, AIA Type Document is attached. 1. ORIGINAL CONTRACT SUM $ 331,500.00 2. Net Change by Change Orders $ 0.00 3. CONTRACT SUM TO DATE (Line 1 + 2) $ 331,500.00 4. TOTAL COMPLETED AND STORED TO DATE $ 331.500.00 5. RETAINAGE: a. 0.00 % of Completed Work $ b. 0.00 % of Stored Material $ 0.00 0.00 Total retainage (Line 5a + 5b) $ 6. TOTAL EARNED LESS RETAINAGE 0 (Line 4 less Line 5 Total) 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT (Line 6 from prior Certificate) $ 8. CURRENT PAYMENT DUE $ 9. BALANCE TO FINISH, INCLUDING RETAINAGE (Line 3 less Line 6) $ 0.00 331,500.00 298,350.00 33,150.00 0.00 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS Total changes approved in previous months by Owner 0.00 0.00 Total approved this Month 0.00 0.00 TOTALS 0.00 0.00 NET CHANGES by Change Order 0.00 The Undersigned Contractor certifies that to the best of the Contractor's knowledge, information and betief the work covered by this application for Payment has been completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the owner, and that current payment shown herein is now due. CONTRACTOR: Smock Fansler Corporation 2910 W. AQiinesota Street Indianapolis, IN 46241 By: T.M. FANS L.ER State of: iN County of: MORGAN Subscribed and Sworn to before me this Notary Public: �.i? CLC4G My Commission Expires : // / CEO Date: 0 0110 r u m"rr(0ai,. PFtY PUg�`C�� /o - /qs A • . Day of c 0 20 [ ARCHITECT'S CERTIFICATE FOR PAYMENT In Accordance v✓ith the Contract Documents, based on on -site observations and the data com- prising the above application, the Architect certifies to owner that to the best of the Architect's knowledge, Information and belief the Work has progressed as indicated,the quality of the work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. AMOUNT CERTIFIED (Attach explanation if amount ce Application and on . _ . tinuati $ 33,150 " ARCHITEC By: ed differs from the amount applied. Initial all figures on this Sheet that are changed to conform to the amount certified.) Date: This Certific not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, Payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract. AIA Type Document Application and Certiflcatton for Payment Page 2of2 TO (OWNER): VILLAGE FINANCIAL LLC 770 3RD AVENUE SW CARMEL, IN 46032 FROM (CONTRACTOR): Smock Fansler Corporation 2910 W. Minnesota Street Indianapolis, IN 46241 CONTRACT FOR: PROJECT: HANOVER SQ FOUNT @ CITY CTR. 770 3RD AVENUE SW CARMEL, IN 46032 VIA (ARCHITECT): APPLICATION NO: 8 PERIOD TO: 12/31(2011 ARCHITECT'S PROJECT NO: CONTRACT DATE: DISTRIBUTION TO: OWNER _ ARCHITECT CONTRACTOR SCHEDULE PREVIOUS COMPLETED STORED COMPLETED J ITEM DESCRIPTION VALUE APPLICATIONS THIS PERIOD MATERIAL STORED _______70 BALANCE RETAINAGE 1 FOUNTAIN EQUIPMENT 181,785.00 181,785.00 0.00 0.00 181,785.00 100.00 0.00 0.00 2 PIPING /PUMP 71,215.00 71,215.00 0.00 0.00 71,215.00 100.00 0.00 0.00 INSTALLATION /ELEC 3 GARAGE IMPROVEMENTS 23,500.00 23,500.00 0.00 0.00 23,500.00 100.00 0.00 0.00 4 PAVING AND SURFACE 55,000.00 55,000.00 0.00 0.00 55,000.00 100.00 0.00 0.00 EQUIPMENT REPORT TOTALS $331,500.00 $331,500.00 $0.00 $0.00 $331,500.00 100.00 $0.00 $0.00 AFFIDAVIT AND WAIVER OF LIEN [X] Final [ ] Partial [X] Payment to Follow State of Indiana County of Marion T.M. Fansler , being duly sworn states that he is the CEO of SMOCK FANSLER CORP. having contracted with: Village Financial LLC to furnish certain labor, materials, and/or services as follows: Misc. Construction for a project known as: SFC #11 -023 Hanover Sq. Fountain a, Clay Ctr. located at Carmel, IN and does hereby state on behalf of the aforementioned contractor: (PARTIAL WAIVER) that there is due from the owner the sum of: ($0.00) [ ] receipt of which is hereby acknowledged; or [ ] the payment of which has been promised as the sole consideration of this Affidavit and Partial Waiver of Lien which 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 balance due from the owner is the sum of (533,150.00) Thirty Three Thousand One Hundred Fifty Dollars and No /100 [ ] receipt of which is hereby acknowledged; or [X] the payment of which has been promised as the sole consideration of this Affidavit and Final Waiver of Lien which shall become effective upon receipt of such payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all lien or claim whatsoever on the above- described property and improvements thereon on account of Labor, Materials, and/or Services, furnished by the undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certifies that no other party has any claim or right to a lien on account of any . work performed, materials, or services furnished to the undersigned for said project, and within the scope of this affidavit and waiver. SMOCK FANSLER CORP. By \Ad; T.M. Fansler Title CEO WITNESS MY HAND AND NOTARIAL SEAL, this 30'h day of December 2011. Melissa J. Bi My commission expires November 30, 2016 �O- nARtiYutP" ���,�iG /ko Bisho Notary P blic =fir: *= SEAL Residing in Morgan County ::5 ....nit•, �/�i /ijUU�ttBU,'� HN1t0�n�a���\\� SUBCONTRACTOR'S SWORN STATEMENT OF INDEBTNESS & WAIVER OF LIEN STATE OF INDIANA COUNTY OF HAMILTON T.M. Fansler Being duly sworn upon his /her oath disposes and says that: 1. He /she is CEO (inserting sole proprietor, partner or corporate office held, as the case mayby), to Smock Fansler Corporation hereafter called the "Subcontractor ". He /she is over the age of twenty one. He /she is authorized to make this affidavit on behalf of Subcontractor. 2. Subcontractor is the Fountain Subcontractor for the construction of the development known as Hanover Square Improvements located in Carmel (City) INDIANA (state), hereafter referred to as the "Development", pursuant to the contract between the Subcontractor and Village Financial, LLC, the Owner. 3. This affidavit is made for the express purpose of inducing Village Financial, LLC, to make payment to Subcontractor of the invoice submitted herewith for labor and materials furnished pursuant to said Contractor. Upon receipt of said payment the Subcontractor hereby waives any lien reights to which Subcontractor is entitled for labor or materials furnished for the development to the date hereof. 4. Subcontractor agrees that upon receipt of the payment amount described above, Subcontractor shall immediately execute in favor the Owner, the "Transfer of Title" document (attached as Exhibit A) for all labor and material furnished to the extent described above. 5. Listed below are all suppliers or other persons who either has furnished or might furnish the Subcontractor with materials, appliances, machinery, fixtures or furnishing placed upon or installed on the development. Mark (X) in the appropriate column for EACH supplier listed. Place an (X) in column: 1.) If a waiver of lien by supplier conditioned by payment of a specified amount is attached hereto. (In this case also show the amount owed the supplier). 2.) If a FULL (final) hen release has been signed and delivered to the General Contractor. 3.) If the initial delivery has not been made. Supplier List (Add list if necessary) Billed to Date Previously Paid Balance Allied Wholesale Electric $286.32 $286.32 $0.00 Apple Electric $3,815.65 $0.00 $3,815.65 Architectural Brick & Tile Inc. $16,051.63 $16,051.63 $0.00 Automatic Irrigation & Supply $164.90 $164.90 $0.00 D Transport Inc. $520.00 $520.00 $0.00 Fastenal Company $16.49 $16.49 $0.00 Harrington Industrial Plastic $5,397.06 $5,397.06 $0.00 HD Supply Waterworks LTD $309.55 $309.55 $0.00 Irving Materiats Inc. $8,328.00 $8,328.00 $0.00 Jobsite Supply $558.50 $558.50 $0.00 Maxim Electric LLC $10,000.00 $9,000.00 $1,000.00 Noblesville Landfill Inc. $210.00 $210.00 $0.00 Rogers & Co. of Indiana Inc. $82.95 $82.95 $0.00 Santarossa Mosaic & Tile Co. $53,867.52 $53,867.52 $0.00 Service Pipe Supply $4,517.94 $4,517.94 $0.00 The Fountain People $181,785.00 $181,785.00 $0.00 Utterback Supply $169.46 $169.46 $0.00 White Cap Construction $127.00 $127.00 $0.00 # 1 and 2 correspond to the same numbered choices on the waiver format. Village Financial, LLC is hereby authorized to make payment to each such unpaid creditor either directly or by check jointly payable to Subcontractor and such creditor, as Village Financial, LLC shall determine. 5. There are no bills, charges, costs or expenses for labor or material which could now or hereafter result in lien being-filed against the Development or a claim being asserted against the General Contractor except the persons or business named in Paragraph 4 above. IN WITNESS WHERE OF, affiant has signed this document on behalf of the Subcontractor this 30th day of December , 2011. State of INDIANA County of MORGAN Subscribed and sworn to before me, a Notary Public in and for said County and State, this 30th day of December , 2011. Yl C X ;A, L7;11 1,0 (Notary Public My Commission Expires: November 30, 2016 Melissa J. Bishop (Print Name) Attachment A TRANSFER OF TITLE Smock Fansler Corporation (Contractor) transfers to Village Financial, LLC any and all right, title and /or interest that Contractor has in any labor and /or materials described in (i) that Affidavit of Waiver of Lien executed by the Contractor on 30 -Dec , 2011, and (ii) in the "Amount of this Request" section of that "CONTRACTOR" By: Printed: Title: T.M. Fansler CEO Smock Fansler Corporation 2910 W Minnesota Street Indianapolis, IN 46241 -4541 Invoice P.O. Num. See Transmittal Sheet for check detail. Invoice Amt 331,500.00 Check: 6 Date: 6/24/2012 Vendor: SMOCKFA1 Prior Balance Retention Discount Amt. Paid 34,563.00 0.00 0.00 34,563.00 6/24/2012 **********34,563.00 THE SUM OF THIRTY FOUR THOUSAND FIVE HUNDRED SIXTY THREE DOLLARS AND NO CENTS * * * * * * * * * * * * * * ** Smock Fansler Corporation 2910 W Minnesota Street Indianapolis, IN 46241 -4541 Smock Fansler Corporation 2910 W Minnesota Street Indianapolis, IN 46241 -4541 Check: 6 Date: 6/24/2012 Vendor: SMOCKFA1 6 Prior Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid See Transmittal Sheet for check detail. 331,500.00 34,563.00 0.00 0.00 34,563.00 Smock Fansler Corporation 2910 W Minnesota Street Indianapolis, IN 46241 -4541 Transmittal Sheet Page 1 Carmel Redevelopment Comm Check: 6 Date: 6/24/2012 Vendor: SMOCKFA1 Prior Invoice P.Q. Num. Invoice Amt Balance Retention Discount Amt. Paid 3 - Hanover Square 100 75,325.25 7,532.53 0.00 0.00 7,532.53 Hanover Square 3 (IPC - Merc) 4 - Hanover Square 100 21,646.50 2,164.65 0.00 0.00 2,164.65 Hanover Square 4 (IPC - Merc) 5 - Hanover 100 20,060.75 2,006.07 0.00 0.00 2,006.07 Hanover Fountain (IPC - Merc) 5 -1 100 94,453.25 9,445.33 0.00 0.00 9,445.33 App1 on P5 Hanover Sq Fountain 5 -2 100 101,164.25 10,116.42 0.00 0.00 10,116.42 App 2 on Hanover Sq Fount City 5 -7 100 1,570.00 1,570.00 0.00 0.00 1,570.00 Hanover Square (IPC - Merc.) 6 Hanover Square 100 17,280.00 1,728.00 0.00 0.00 1,728.00 Hanover Square (IPC - Merc) 331,500.00 34,563.00 0.00 0.00 34,563.00