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rlA »n MECw?wics~ RAMCO FORM 120~'S
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Before me, the undersigned authority, personally appeared f7Q.~M...l.°5
who, being duly sworn, says that h/e is the lienor herein a the agent of the lienor herein, .
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(Lienor's Name) r
whose address is ..i'„~,~..~'r~......` . ~.'.E~l.n......../~. ~ .......`/r.'.•~j~...,...I.....:..d .
(lianor's Address) -
and that in pursuance of a contract with...... C~.!~.....~... ~.~.1. ~..J~,.~'. t~.
lienor furnished labor, services or materials consisting of: (Describe specially fabricated materials separately)
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on the following described real property in.....r.%...1. L tJ.c.t.e.....~.~•.v.,~.~ County, Florida:
(Describe real property sufficiently for identification, including street and nu~ber, if known)
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l: c! O ~tJ:J fl' c! 6 J c ~ S c b t~ ~ •
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owned by . l..t?,-y._ S°'^. ~J.~'.: ~f . %
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ofatotalvalueof..-..-~.~'i..lC'~?....~.utls~.r~°.~1.....k-..~.t":-1.~...........dollarslS.. -
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of which there remains unpaid S . - t~ ~ - - • ~ - - - ~ - - ~ - ~ ~ - ~ • • ~ - - • - ~ - for which amount he claims a lien on the above
described real property.
~ He further says that lienor furnished the first of said labor, services or materials on
__._..___._.....-...-.,19..........,and the last of the sameon.~.vi..-.-~... --~..!.---.-.19...-......,andlifthelien
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s is claimed by one not in privity with the owner) that the lienor served his notice to owner on ..I~..-
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.......................:............19..-.-.-.... by----...~1.~.....fl~~.s ~ ~v....................-..........-..
(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)
on ......................................................19..........,by.............-..........-.......---........-
(Method of Service)
and additionally, (if the lien is c!eirned by one not in privity with the subcontractor) that the lienor served a copy
of his notice to owner on . .
(Subcontractor)
on..._._....... ~FF--11l,EppAh;, • :.ti..•~Ex: S .19.........by...............-.................------...~. -
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CLEPr ~ . ^;lR1 "I ' - t L tom: 'y~~ >l:
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I 13 1 X1'7` LienQT n;~ ~ '~~:.~''•-.~:~'eS
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Sworn to and subscribed before me this_ .....................day of ..~.t'..Q.'..~!,,~D~:!•!',~;~,•'> .
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` 1 Notary Public
('his Irrslnrnu~nl prr•par~•rl hy: \J
.•1 rf'rlrrss - - _ ND1Atf t'NILIC AAiE Of ADLJOiA Ai WI'it i`
.~.~,...~v~ rr GOAiAA11SfON WIRlS IIIIS. M Ifli~ !