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202500422 <br />The first day of the Work on the Property by the Claimant was <br />05/01/2023 (mm/dd/yyyy). The last day of the Work on the Property by the Claimant <br />was 05/16/2023 (mm/dd/yyyyj (the "Completion Date"). <br />As of the Effective Date, the Claimant has: (check one) <br />El Received payment of $14,968 <br />❑ NOT received any payment. <br />The Owner has failed to pay the Balance Due despite demands and requests for payment. <br />Accordingly, the Claimant declares that claim amount of $6532.00 is justly due to the <br />Claimant. <br />The Claimant declares that t - contents of this Lien are true and correct to the best of their <br />knowledge. Subscribed a am to as of the Effective Date. <br />Claimant Signature: <br />Date: <br />Claimant Printed Nam <br />Jason Heftier <br />NOTARY ACKNOWLEDGMENT <br />State of oslG�i <br />County of ( I <br />The foregoing instrument was acknowledged before me this/(!9. Z% 2_02S, by the <br />undersigned, jaran 4• /-f//&r , who is personally known to me or satisfactorily <br />proven to map bA the on whose name is subscribed to the within instrument. <br />Notes/ Public I <br />My Commission Expires: 7UhG <br />eSign <br />Page 2 of 3 <br />