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Bsfore ms, Ihs undersi~ned aWhority, personally appeared
who, b~in~ duly sworn, says that he is ths lienor herein or ; ~he~a9~ ~ of the lienor herem,
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(lienor s Nama)
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whose address is ~
(lieno~ s Addross)
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and lhat in purwance of a cantrad with
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lienor fumished labor, services or materials consisting oF: (Describe specially Fabricaled materials separately)
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of a total va~lue oF ~~r
oF whith there remains unpaid s~' , for which amount he claims a lien on the kllowing
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desuibed real property in ~ County. Florida_
(Desuibe real property su ntly ~dentiFiwtion, indudiny streel and number if known)
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~ :sy~
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~ Owned by
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Hs furiher ys t(ienor Fumished the (irst of said~laKor, service~~ materwls on v
19~~.~., and the last of the same on .3 19'~ and (if the lien
is daimed by one nol in privity with the owner) that Ihe lienor served his notice to owner on
19 by _
(Method oF Service) ~
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fILfD AND RECURDcU ~
~.l~~O ST lU~{E "vOUNTT fLA x~~.'L'~' ` ~'!-~.l'~----
. ~ r ° . POl. ~ ~ ~ ~ f ~ienOr/ .
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~ 00 I H~` l AgeM or Attorney
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~ Swom'.fo snd~w~sdibed bsfore ms this.... .......day oF y~'~` 19~ ,
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~ - . . • ' : ~ ~ ~ Notary Public
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~ 7 ~i 1>tt1~~Hiwul. '+ir fNrr«l l~ ,
1f~ 1~ IVf~T1av n•.,.r~ e.~ve nr r~n~~;~A AT la£GE
r ~^A~ COMMISSION Ex~~RES fFB. ?3, Iq79
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