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200509362 <br />Claimof Lien i ................................................................................. I .................... <br />State of <br />County of <br />Before me, the undersigned Notary Public, personally appeared FG in a V 3 FLktq_V S <br />who duly swo says that he is he lienor herein) (th agent of the lienor ein) wh K addres ) �`' 10 V` <br />6 <br />and that in accordance with a contract with .G I.A <br />Ij nor furni ed la oL services o materials consisting of: (Describes dally fabricated materials <br />separately) <br />on the following des �f ibed eal property, in County, <br />State of <br />(Describe real pro erty s fficientlY0 identification, including street and number: <br />u vi <br />U fVt cfury <br />owned <br />by "i e �. 1n i tM E of a <br />total value of Dollars �� ) <br />of which there remains unpaid Dollars ($ Q ), <br />and furnished first of the items on a ` Q , 20(9 6 and the last of the <br />items on `7" 13 , OS— 206-1- <br />0 6 and (if the lien is claimed by one <br />not in privity with the owner) that the lienor served his notice to owner on <br />20 by <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 .. on <br />, by <br />and on the subcontractor <br />and (if known) on the <br />(Method of Service) <br />Page 1 <br />wvvw.socrates.com ¢ 2004, Socrates Media, LLC <br />LF136 • Rev. 04/04 <br />