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<br /> � � 221•A—MHCHANIC'S UEN (Revlsed 1962) T6e FiuA�an Ge�eral aupy,y H�ux,Liucotn,N<br, f . � .
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<br /> , ' duly szuarn,on his oath sc_�s tlrat tlic foregoang+temised acrosvU o�work,Ia6or,skill....1dGOP........-•-•---......--••..................• i
<br /> � '% materials,nnd i»sproveir�erits s true nnd rorrect: tlwt smne zeese done and herforured and furnished 6y!he undersigned i
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<br /> �. � under a' ........_v�3'�al......................................... rontract......._........----.............................................---........_..........---........._--
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<br /> t '. � I ----------------•..•...•....�phe£ta�Suodivision_to_.the...citY.._of...Grand..��rl.ana-----�-�----------�---..........._...........--•-•----._.......... � ,'
<br /> ° Hall County hebraska
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<br /> " � Tlrat at thc titr�e aaid rontract uas»sude�rnd IuLor and »mterials furnislicd nnJ dclivered theresaidrr......_............... � '
<br /> � I ....__..--•................__..........-- --�--...---•---......._..._...........---...........---�-----..........----........._........:vas thc ozvnrr o(said pretnues �
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<br /> ` ' '.; Tl�at the Jate of tAe first item Jurnirhed anJ deliverrd xeas......-----5:-1Q.-7-b.........................................---....... and the �
<br /> ' ! J date of fhe larf item was.....-�--�....................�,.�..�.Ei....__........................................-----..........................................................
<br /> ; I AQ'iant further stoter that said labor auas pe�iormed on,mid materwls u�cre furnishrd fas, de(ive�ed at,and used tn i i
<br /> aaid building or prernises on anJ betu�een the dafes .cpecihrd.
<br /> That the Qrices charged Ihere(os a�e fair and feasonaLle, and that there is noxu due an said accoant the sum of � '
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<br /> •' ,i' raid account, to-wit: The sum of$.............................................._.......---_togetker xuiUi inferest thereon at the Iegaf rate, � .
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<br /> ' ' SEAL Subrcribed in my presence and sworn to before me fhu.........._14th._.__,.___.
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<br /> i (See reverse siJe for instrnctions) Mr Comm. L 21,19 ry Pu6(ic. ! I _
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<br />� ' � STA'I'E OF............._.............._----•--....._...._..................1 lntercd on numerical inder �nd filed for record �
<br /> . � � I Coun }�� in the Regi�ter ot Deeds O(fice of xaid County the � ���� � � �� �
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