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FLA. 1067 LAWS 24Sgs9 ; l1AMC0 ~ORM It0•
F8 71J.09
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• P. L. Gould~ M. _D.~......... _
Bsfore ms, the undersi~nsd autlwr~tY, Personally appeared
the a9ent
who~ bein~ duly sworn, says Ihat he is th~~ lienor herein or ~ the attarney ~°f the lienor herein,
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P. L. Gould, M. D. -
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(lienor s Name)
3701 Broadway, West Palm Beach~ Florida _ 33407.__ . ;
whoss address is _ . _ .
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(lie?wr s Address) _
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and that in purs::anoe oF a contrad with...... Frederick..R. .Pease _
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. 3326 Sunrise Bouleyard,...Ft._ Pierce, Florida 33450. . . . , ;
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(ienor Fum'~shed labor, services or materials consisting of: (Describe specially fabricated materials s~parately~
Medical Services and Surgery ~
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of a tofal value of. .......One Thousand two hundred twenty ~~an (s 1, 220. 00 ~ '
oF which thero remains unpaid s 1, 220..00 For which amount he daims a lien o~ the fdlowin9 `
Bank Account St. h~cie
desuibed raaL~copscqc in.__.... . . _ _ County, Florida:
(Deuribe real property suHiaeMly For identification, induding streei and number if known)
First Federal Savings ~ Loan of Ft.Pierce f)LE4 hy. ~=~~~~EO
Account ~411Ly ~1 ~UC+c ~,3UNiY f~A.
ROG~; rJ;TRAS ~
CtEit~ ' ~u'T COURT Y~..
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~ Frederick R. Pease
° Owned by- _ _ .
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~ Hs hxther says that lienor furnished the first of said labor, services or materials on
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~ June 14 19.72 and the last oF the same on .--.January.. 9..-- 19 _72, and (iF the lien
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4 is daimed by one nol in privity with the owner) that the lienor served his notice ro owner or?
` Januar 9 19 72 , by. _ . Statement ~ . ;
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~ Swom ro and wbsaribed bsfore ms this..........~:J ..............................day of .~~~<--~:t~ __...._.._...t9-_~~ =
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N07ARY PUSLIC STATE OF it~lQ~,11 ATL~ ,
MY C0..1?..ISSION EXPIRES !t7~Y `
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~ Ihis 1»sinn~~f~n ~np~~ri~l l~ : Vera G. Carey ~E~l INSURANCE UNDERVI~t1 .ry~
/l chlrr~ss 3701 Broadway ~ - " .
West Palm Beach,Fla. 33407
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