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<br /> j r 4 2. The person ag�n�whose intsest in the real estaLe the tien is d�med i� , f:«'".,--
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<br /> .. . -_ of the etaimant i�sJ11an n e e w -�r O��oZ� �• (/S �. C= -
<br /> . 3. The name and address sy ' -�`—'� _
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<br /> _ . 5. A general desc�iption of ttce claiman�s sernioPS performed to.to be perfozmed ar aaaterials finnishe�l or to be �:: ... .�
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<br /> - ' • . . fnmished f�the imprnvennent and the aontrad p�tioe is . �'::.-. _
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<br />�' � j: 6. (Complete one of the following) �'a`°
<br /> F.��� • � The amount unpaid.whether due or not.to the ctaimant for the services or materials is$ 1� -
<br />'�:. :,:� but a ood faith estia:ate u�the amount of� .
<br /> " ' . . . The unpaid amount ia not figed by the oontsad. g ��::
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<br /> . �.' 7. (Complete one of tlie foll g) �
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<br /> . � � .;� � The time the last servioes or materials were fumished was �-`o�-�/ • �•-"-;
<br /> ., . . , ���1 -
<br />-"� _ .. materials were fumished �as not yeti oocurred but is estimated to ooc�s --
<br /> ;, . � The 13me the last servioes oX . - ��`
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<br /> .: ' Si�aature Claimant . '
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<br />�:` .� : . q �y� �g �i $ •
<br /> � . " ,., Subsribed and sworn to before me this ' �
<br /> � .`, . � GENER11LftOTAAT•StattallteLrlsla -- -
<br /> • II NARIA&FANDRII otarY PubliC .----_.
<br /> irytomm.Eip�eD.l).2001
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<br /> � �i,' , (5�l4Z See 52�l48 for amendment;52�149 for assignment;b?r137 fo=reaording tim�5�154 for discha�e or release). �
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