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raw ma Mtwu?wics• RAMCO FORM 120 K
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(~j~ttl~i ~t~n
4642
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~ St. Lucie 1
Before me, the undersigned authority, personally appeared JAx'X'.3t...~k1AA113.;t...w.~.RP~.Y).~
who, being duly sworn, says that he is the lisnor herein or the agent of the lisnor herein.
Jerry.. Thomas•..Wig~ins...................................................................................
C ~ 0 1',30 ~ 3 ? ~ 1 ~ (Usnor's Name)
whose addressis......3056.-Oleander•.Bouleverd-,---Fort.-Pierce.,--.Florida, .33450...._,
- (lienor's Address)
and that in pursuance of a contract with Gl OI`i:~-..8 t1d • . At'lt 011•i O . - Pa di 1 ~.,a. • • -
lienor furnished labor, services or materials consisting of: (Describe specially fabricated materials separately)
Transmission, Battery, Generator, and Vale?es. Labor was also
furnished.
on the following described real property in.......St-.-..Ll]C~9 .......................................................County, Florida:
(Describe real property sufficiently for identification, including street and number, if known)
1974 Continental Van
owned by Mount-f:in Credit,--.and-•Gl.oria & • Ant-onio-..Pa.cl ~.lla-
of atotal value of .....0x18..ThOt:.B&nd .......dollars (S 1y000~.40-..........
of which there remains unpaid 5.8.911..~~.-.-----..-- for which amount he claims a lien on the above
i
! described real property. '
He further says that lienor furnished the first of said labor, services or materials on
~ S8.}?t.AFltJ.~7C ,197.9....., and the last of the same on.~e n.t e.mb...r....15.-... , 197.9...., and (ii the lien
is claimed by one not in privity with the owner) that the lienor served his notice to owner on '
October..16 ...............,19.79.... by...'~erbal,..,;i.t.ns.s.~e.d...by..Ft.....~.ie.r.c.e...Police.......... .
(Method of Service) -
and, (if the lien is claimed by one not in privity with the contractor) that the lienor served a copy of his notice to
owner on
(Contractor)
(Method of Serv~Wll._~~j?li;
and additionally, (if the lien is claimed by one not in privity with the subcontractor) that the lispof p~CVSd's,a~` .
of his notice to owner on ~ -
........................(Subcontractor).............._..... _
.
(Met of Servic9l
..7....
Lienor
X19 I7 P. 3~ 0I
13y_
FI.EC p'~` ~•i,r:.;i ~ l Agent
ST.f_UCtECG~t1iY.~k ,L
ROGER F'OtTf: J
Sworn to and sup~~6Wi<orstne _ ._day of ...~i,~.~- _.......1
.r~
C _ ~ Notary Public
l'hi~ I?i.~lrr~?nr•nf prr•pnrr~d b~~: -
IVpTA1Y «.f11~; ttA1t (1F Rf1RIpA AT LAR(•~E
1 rlrlrv~.... Ai11? co~tMlssloN exrtltts FFS. 43, 1970
nwl4~ ~ sOPIOED 1HRU CaENfItAI 1N«RAI~E tINOERINR~TER3