HomeMy WebLinkAboutBroady-Campbell, Inc. - Prime Contractor's Sworn Statement of Indebtness & Waiver of Lien PRIME CONTRACTOR'S SWORN STATEMENT OF
INDEBTNESS &WAIVER OF LIEN
STATE OF Indiana
COUNTY OF Hamilton
Scott Broady Being duly sworn upon his/her oath disposes and
says that:
1. He/she is President (inserting sole proprietor, partner or corporate office held, as the case maybe), of
Broady-Campbell, Inc. hereafter called the "Prime Contractor". He/she is over the age of twenty-one.
He/she is authorized to make this affidavit on behalf of Prime Contractor.
2. Prime Contractor is the _Masonry_ Prime Contractor for the construction of the development
known as VILLAGE ON THE GREEN — PARCEL 7C1 — THEATER BUILDING located in CARMEL
(City), INDIANA (state), hereafter referred to as the "Development", pursuant to the contract between the
Prime Contractor and CARMEL THEATER DEVELOPMENT CORPORATION, LLC., the Owner.
3. This affidavit is made for the express purpose of inducing and CARMEL THEATER DEVELOPMENT
CORPORATION, LLC., to make payment to Prime Contractor of the invoice submitted herewith for labor
and materials furnished pursuant to said Contractor. Upon receipt of said payment the Prime Contractor
hereby waives any lien rights to which Prime Contractor is entitled for labor or materials furnished for the
development to the date hereof.
4. Listed below are all suppliers or other persons who either has furnished or might furnish the Prime
Contractor 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 Owner. 3.) If the initial delivery has not been made.
Supplier List (Add list if necessary 1. Amount Owed 2 3
Architectual Brick t, I ile 21,1b2.4:3
#1 and 2 correspond to the same numbered choices on the waiver format. CARMEL THEATER
DEVELOPMENT CORPORATION, LLC.is hereby authorized to make payment to each such unpaid
creditor either directly or by check jointly payable to Prime Contractor and such creditor, as CARMEL
THEATER DEVELOPMENT CORPORATION, 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 Owner except the
persons or businesses named in Paragraph 4 above.
IN WITNESS WHERE OF, affiant has signed this document on behalf of the Prime Contractor this 31st
day of _January_, 2011 .
� G5
(Authorized Repre ntative of Prime Contractor, Title)
County of Marion
State of Indiana
Subscribed and sworn to before me, a Notary Public in and for said County and State,
This 31st Day of January , 2011
(Notary Public)
Denise E. Broady
(Printed Name)
My Commission Expires:
NOTARY SEAL MUST APPEAR ON THIS FORM.
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