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CLAIM OF LIEN
STATfi OF ~ iZ~ D A :
COUNTY OF ST . ~...JC~\t, s
Before me, the undersiqned authority, personally appeared
~c.o~ 's , who, being duly sworns says
(name of ienor)
that he is the (lienor herein) (the agent-attorney of the lienor
herein) whose address is ~j~ ~ ~,DW A~teS ~o.~~-'~.~~ce~
.
and that in pursuance of a contract with ~SZ P.~1-co~rv
(narne of purchaser)
Co~P A~Y , tienor furnished labor, ser.vices or materials
consistinq of k~tu~Fw~1~~3~•~~js ~~`r~oo,~, ; on the fol-
(description of materia s)
lawing describea real property in ~.,.uL.~E County,
(name of county)
Florida; owned by QPt K~F.~1E~.oP~aT Co~~oaRt•orJ ; of a total
(name of owner ~
value of $ 52-- a~ ; of which there remains unpaid
(value of material)
$ Lj3Z~8 ; and, furnished the first of the same
(unpaid balance) ~
on ~Q> , 19 , and the last of the same
(date materi 1 first furnished~
on ~ 2~ , l~ , and ( if th~ lien
(date materi 1 1 st furnished)
is claimed by one not in privity with the owner) that the lienor
served his notice to owner on , 19~_,
(date notice to owner served)
.
by ri~tu ?Mo REC~Rj~A.
st, ~~ci~ couK Y ~
• IIOCE~ PO~TMs
Sworn and._ suLi d before ine c~ERK c~~cu~T eou~
- ~ ~ ~ H:-.~ aECORD vEp~FiEO
- ~ . 12 09 PM'T~t
thi pf , 19~. ~ ~Q
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