Fill and Sign the Notice Contest 497302792 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ___________________ Address: _____________________ City: __________________________ State: _____ Zip: _____________ Phone: _____________________ Fax: _______________________ NOTICE OF CONTEST OF PAYMENT- INDIVIDUAL TO: Owner _______________________________ Owner's Address ___________________________________________________________ Lienor _________________________________ Lienor's Address _____________________________________________________________ Surety ___________________________________ Surety's Address _____________________________________________________________ Under penalties of perjury, the undersigned certifies that the contractor has not been paid or has only been paid $ _________________ for the labor, services, and materials described in the Certificate of Payment to the Contractor recorded in Official Records Book ________ at Page ___________ , of the Public Records of ________________ County, Florida. DATED this _____ day of _________________ , 20 _____ . Signature _________________________ Printed Name _____ _ ________________ Address ___________________________ Notice of Contest of Payment Page 1 of 2 STATE OF _____________ COUNTY OF _____________ Sworn to (or affirmed) and subscribed before me this _____ day of _____________, 20_____ by _________________________ (name of person making statement). _________________________ NOTARY PUBLIC Print, Type or Stamp Commissioned Name of Notary Public _________________________ Commission Expires _________________________ Personally Known _________________ OR Produced Identification __________________ Type of Identification Produced _______________ A copy of this Notice of Contest of Payment has been served on the owner, lienor, and surety at the addresses shown above on this __________ day of ________________, 20____. CLERK OF THE CIRCUIT COURT By: ____________________________ As Deputy Clerk (COURT SEAL) Notice of Contest of Payment Page 2 of 2