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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 />ev <br />By <br />State of <br />County of <br />Agent <br />On iilec y . 19, Z06'=' before me, <br />appeared 0,p,x �f E 0 > <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 official seal. <br />Signature P ,� � Y' k % <br />Signature of Notary Affiant Known Produced ID <br />Type of ID <br />G MAl owUlle of Nebraska <br />MNERA M RTCHHORN <br />My One& ft Mi. 26, 2004 <br />(Seal) <br />A E -Z Legal Forme. 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 />