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the date of See t � 20 /3 . I hereby, under the laws of the State of described property in the amount of money, stated above, which remains unpaid to me. Address of person claiming lien: 3O5 Qeachc.Vo c Qt • Grand Island, ll)e 6 NOTARY CERTIFICATION FOR CLAIM OF LIEN State of County of s rn On lJ (date), 4 / Z a / 3 (name of claimant), came before me per- sonally, and duly sworn on oath, and under penalty of perjury, stated that he or she is the claimant described in the above claim of lien and that he or she has read the foregoing claim of lien and has knowledge of and personally knows the foregoing statement of claim of lien which he or she subscribed is true and correct and is not frivolous, nor clearly excessive, and is made with reasonable cause. Subscribed and sworn to before me on the above noted date by the above noted claimant, and proved to me on the basis of satisfactory evi- dence to be the person who appeared before me. c'75/a1-17 l• Notary Signature Notary Public, In and for the County of State of .— My commission expires: CERTIFICATE OF MAILING /v e b eas Ir( Seal 201308446 , claim a lien against the above- 6.--: /k d `t Name of erson ' Lien GENERAL NOTARY - State of Nobuaki' KATHY A GOOSIC My Comm. Exp. May 1, 201? I, -c.i , certify that on this date, /b — J ' - /3 , I have mailed a copy of thi laim of Lien by USPS certified mail, return receipt requested, in accordance with the law, to: Name: v 4 K� //to/ups & t Address: ' O. 8o* 3O/ Date: I )4 7 . %SS 93 - /0-/713 c :S 9 , ignat= Maili g Claim of Lien Name of n ailing aaim of Lien *NOVA LF136 Claim of Lien Pg.2 (07.11)