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