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- ftA ~s~i MEt+~~Nict~ ~ ~ RAMeO fORM 120s4
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- Before me, the undersigned euthority. Personally eppeared
who, heing duly sworn, says that he is the lienor he~ein or the agent f the lianor he ein .
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Lienor's Name)
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whose address is , _ -
~ ~ Lien~~ress)
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and that in pursuance of a contrgct with .
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lienor furnished labar, services or materials consisting of: {~jescrilse specially abricated materials separately)
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f - on the foilowing described reai property in County, Floride:
~ (Describe real property sufficiently for identification, including street and number, if known) ~
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oh sf -
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owned by...~ .
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of a total value of ~ ~ ...:.......................doliars (S
' of which there remain~ unpaid S..~..'.•O • DO - , for which amount he claims a lien on tha above
described real property. - _ '
He further says that lienor iurnishe~ the first of said labor, services or materials on
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~ is claimed by one not in privity with 4he owner) that the lianor served his notice to owner on -
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. 19~2.., by . ~}e~4.~'4.............................._......- .
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and, (if the lien is claime by o e t in privitx with the contractor) that the lienor served a copy ~f his notice to ~
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~ce-.~ ~or~~s I_rtC_ . . -
- owneron
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on . 19Q..~,-., by......:.... . ,
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and additiona!!y, (if the lien is claimed by one not in privity with the subcontractor) that tha lienor served a copy
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~ of his notice to owner on ;
iSubcontractorl .
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~ . . 19......---~, by..........:..................-•----•-•~---•---...-----......... .
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(Me of Service) _
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, ~~I V ! ~~t ~!;C F'''~,:s•r ; Lienor ~ ' ~ s
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' CIFNK C1i~CUiT CC' ~~i ' By ~ ~
. f. _ r, Agent '4:''~ , - tr~;,' '.~``s
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•----..da of l,~' ....:..j....._..~ 19 ,
Swom to and subscribed ~efore me this _......~_7__......._.. `tL.
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~ Notary Pu .4., .
17ii~ I~+•Ir~~n~,•ril ~~r~•/~nrr•rl h~-: Noiery Public, S te ot Florida atta"t~~s i'"'~' •'r.'.•
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My ~ommission Expir~s Apri) 19, 19$~
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