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FLA. 1867 LAWS 11AMC0 iORM 120M ~
Fg ~,3~ 2~'7934
l~tim ~af ~.~t~e~t
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B~Fort ms, tM w~d~rsi~n~d authority, ptrsonally appeared . - ~
~ the agent ~
who, beiny duly sworn, says that h~ is tht lienor herein or ~ of the lienor herein,
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(lienor"s Name1
whos~ addrsss is_ . . ~ • , ;
(lienor's Addrass) ;
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and that in pu~suanoe of s oontrad with . . ,
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~ ~ (i~nor fumishad (abor, s~rvioes or materials oonsisti~g of: (Desc~ibe spec~ally fabricated materials s~parately)
` ~ FILED AIIO RECORDH
ST. lUC1E COtNITY Fll
ROCEF POItRAS
° II ' RECORD VERIFIED ~u~`~U
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` tj ' N~r t t0 4s AH'T I
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R ! 2~ 7934
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a ;
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of a tolal value of . . - - - dollars (s ' ' )
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~ of which thero rsmains unpaid s ' , for which amount he daims a I~en on the following
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~ described roa) prop~rty in - County, Florida:
~ ~i (Uescribe real propKty wfficieMly for idsntificalion, indudiny slreet and number ~f known)
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Owned b
~ H~ hxther says thst li~nor fumished the first of said labor, serv~ces or matenals on
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'r 19......... and the (ast of the same on _ , 19 , and (if the lien
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- is daimed by one nd in privity with the ownsr) that the lienor served h~s not~ce to owne~ on
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. _ . . 19 : . , by .
_ (Method oF Service{ /
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Lienor
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- s AgeM or Attorney
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_ < Swom to 'snd subscn~d b~Far~ nw this.. . . ..f _ _ day of /j' ~ ~ ~~r ~ ~ 19 7 .
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` ' Nolary'Public
~ ~~y~ Np1At'f PliitlC fTATE Of ftM~A At WIiE
- /7,« /,r~~nu,~rn~ prrFnre~J l~y: ~ t~~ Mr ~~~~n~~.,~wH t.x~~~k:~ rw. lb. ~~n
~ ~pppf~ fNMI F!~ N. NiSTELU@R~T
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- a~RK196 PA~E2183
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