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Bsfors ms, th~ undsrsi9n~d autlwrity. Pe~sonally appearsd.l,.~~~~..~_. `'~~~f'
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who, bein~ duly sworn, says that he i: the (ienor herein or tha attornsy of the lisnor herein,
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(lienor"s Name) . .
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whose addreu is `'~~l ~f ~~L-~=}~/r' ~
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(lienor's Addreu)
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and that in pursuance of a oontrad with ~r~Y/~~.._...L..--r~~,%-`~l /~'lj~~lG~!~'~ i
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lienor fumishsd labor, servioes or materials consislin9 of: (Describe specially fabricaied materials s~parately) ?
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of a total value o~./.~'~/«~1.~1~~a -5%~?f~l ~i~' '/l~' dollars (S )
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of which there ~emains unpaid S~~'7` • ~ , for which amoun! he daims a lien on the (olbwing ~
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desCnbe~ ree~ PropertY tm - _ L. _ - ~ouniY„iivrioa: ;
(~esaibe real prope?ty sufficienlly for identification, i~duding street ~nd number if known) i
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He Fu~ther says that lienor fu~nished the first of said labor, services or materials on ~`~L_'~
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! is daimsd by one rwt in privity with the owner) that the lienor served his notice to owner on
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(Method of Service)
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Swom fo and wbsrnbed bsfors rrw fhis . y _ . .
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to~t~uss~on Exp,res July 4. 1 .
{ p ~ d e d h y k~ r::on F~r ~ b C..wlry Co ~~/~y~`p,~ j
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