State of
County of
Before me, the undersigned notary public, personally appeared , who was duly sworn and says that he is (the lienor herein) (the agent of the lienor herein) , whose address is
and that in accordance with a contract with , lienor furnished labor, services, or materials consisting of
on the following described real property in County, Florida:
Legal description of real property
owned by (Name and address of Owner)
of a total value of $ , of which there remains unpaid $ , and furnished the first of the items on , 20 , and the last of the items on , 20 and (if the lien is claimed by one not in privity with the owner) that the lienor served his notice to owner on , 20 , by and (if required) that the lienor served copies of the notice on the contractor on , 20 , by and on the subcontractor, , on , 20 , by .
(Signature) |
| Sworn to and subscribed before me this day of , 20 . |
| |
(Notary Public)
My commission expires: |
