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200004131 <br />_f _ <br />and, (if required) that the lienor served copies of the notice on the contractor on , 19 , <br />by , and on the subcontractor on , <br />(Method of Service) <br />19 , by <br />(Method of Service) <br />Lienor <br />By <br />State of ne,cxs- <br />County of tOt L <br />Agent <br />On J�1ccy, i9, ZU,JZ' before me, , <br />appeared Ontt -, �e E - /i <br />personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) <br />is /are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her /their <br />authorized capacity(ies), and that by his/her /their signature(s) on the instrument the person(s), or the entity upon <br />behalf of which the person(s) acted, executed the instrument. <br />WITNESS my hand and ofVLL iiciiall seal. __. <br />Signature �GC, .1 11 <br />Signature of Notary Affiant Known Produced ID <br />Type of ID <br />NO>a1U RT H Nebraska <br />ix SA M FIT(:HHORN <br />My CwmL 0% RL 28, 2004 <br />(Seal) <br />O E -Z Legal Forms. Before you use this form, read it, fill in all blanks, and make whatever changes are necessary to your particular transaction. Consult a lawyer if <br />you doubt the form's fitness for your purpose and use. E -Z Legal Forms and the retailer make no representation or warranty, express or implied, with respect to the <br />merchantability of this form for an intended use or purpose. (Revised 10195) <br />