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Claim of Lien <br />....................... ............................... <br />State of _ N P <br />County of H <br />200409818 <br />Before me, the undersigned Notary Public, personally appeared McElroy Service Co. <br />who duly sworn says that he is (the lienor herein) (the agent of the lienor herein) whose address is 807 Claude <br />Road, Grand Island, NE 68803 <br />and that in accordance with a contract with Kevin Woodward (Woodward Construction) <br />lienor furnished labor, services or materials consisting of: (Describe specially fabricated materials <br />separately) Furnace, Air Conditioner, Fabricated Ductwork and <br />Labor to install <br />on the following described real property in Hall <br />State of Nebraska <br />(Describe real property sufficiently for identification, including street and number: S i ng 1 e f am i 1 y <br />residence at 202 Redwood, Grand Island, NE 68801 <br />County, <br />by Douce & Jennifer Beilby of <br />totalvalueofSix Thousand One Hundred Twenty seven Dollars ($ 6127.00 ) <br />of which there remains unpaid Four hundred Seventy Two Dollars ($ 472.00 ), <br />and furnished the first of the items on March 22 20 04 and the last of the <br />items on June 8 120 O4 and (if the lien is claimed by one <br />not in privity with the owner) that the lienor served his notice to owner on October 12 <br />20 o4 by Certified Return Receipt Requested <br />(Method of Service) <br />And, (if required) that the lienor served copies of the notice on the contract on <br />20 , by <br />(Method of Service) <br />on 20 , by <br />lender <br />on <br />Page 1 <br />and on the subcontractor <br />and (if known) on the <br />by <br />(Method of Service) <br />www.socrates.com © 2004, Socrates Media, LLC <br />LF136 • Rev. 04/04 <br />