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, - ~ RRMCO FORM 12055
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BeEore me, the unde~signed auihority, personaily appeared
who, being duty sworn, says that he is the lienot harein or the sgent t the lieno here
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(Li nor's Addressl
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and that in pursuance of a contract tvith •
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lienor turnished {abor, service os materials consisting ofc {Describe specia!{y tab~Cted materials s parately)
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. ......~.....County. Florida:
ot~ the following described ~eal property in .
~ (Describe real property sufficiently for identi(ication, including sireet and number, if ~zosrsrnl
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owned b . -
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of a total value of / C.~C~
fer whicP~ amau~t he ciaims a lien on the above ~
- of which there remains unpaid 5..~.~~-~•~
described real property. ~
He further says that lienor furnished the first of said labor, servi:as or materiais on
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,~w!`e- ~2_......_ ,19..~Z and 4he last of the same on_:..5 . 19g~: and (if the lien
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' is clairr~ed by one not in privi~y with the owner) that the lienor served his notice to owner on -
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and, Iif the lien is claim d by on not in pri:ity~with the contractor) that the lienor served a copy of his notice to
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owner on
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on . ~9.~T.Z., by...,...... . . 5....... ,
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and additionally. (if the lien i~ claimed by one r.ot in privity with the subcontractorl that the IienQr served a copy
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of his notice to owner o~ .
lSub~ontractorj • - -
on : 19.........., by.....:............. - . .
- ~ ~ thod f ervice)
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Swam to and subscribed before m~ this.---.--._-I-~---...-------------------slay of • .
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; Notary P blic : ,~{•`s ~
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'17~i• Iri•~~~ir~~,~iet prr~e~n~•d 1?~~: Nofary Public, Staf of Flarfda a~ Carg~' `.~~/,rf,,,;.:.~- -
My Commission Expires l~lpril i9~ 1985
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