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STATE OF FLOR[DA
~ ~ DEPARTMENT OF HEALTH AND REHABILITATIVE 5ERVICES -
? r TALLAHASSEE 32301
HOTICE of LlEN
Client Number C 1Q0 531 ,
Lien Number 2-8 -
Pursuant to the provisions of Section 402.33(7) (a). Florida Statutes, notice is hereby given that there have been assessed..
pursuant to provisions of said law, a~aainst ~05f~~Obll~lr
a liability for payment of fees to the Florida Department of Health and Rehabiiitative Services, pursuant to the provisions of said
law, the sum of i unpaid fees, wluch after demand [or payment thereof remain unpaid, and that ~y virtue of the
above mentiontd law the amount of said fee. constitutes a lien in [avot of State of Fbrida Department oi Health and Rehabilitative
Servicea upon any title or intenst, whether kga! or equitabk. in any real property, chattels realt or personal property of said tlient
or rasponsibk party.
Period~ for wWch fees hav~e been assased. and the amounts thenof, are as follows:
~ ldonth/Year Fee Assessed Month/Year , Fee Assessed
i
,
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; July 10, 1975 - -
' April 30, 1977 @
~121.Q0 2,626.87
May 1, .1977 - ~lan. 27,
1978 @ Z8Z1.00 7,254.00
Fi l i ng -Fee 4. 00 ~ '
i
z
ti
~ Total = 9~884.87 . s ~
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~ This 23rd y March ~ A.D. 191$_-. ~
~ da of
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~ SfATE OF FLORIDA DEPARTMENT OF HEALTH s
~ This Instrument prepared by AND REHABILITATtVE SERVICFS i
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~ Terr Holt, Cashier, Florida State Nospital _
~ (Namej - . ~
~
~ Chattahoochee, Florida Administrator
; ~Addre~ ~t Florida State Hospital
Has Fo~+ sw. ~~i n jO~Otc ~8~ MCf f
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