NOTICE OF CONTEST OF PAYMENT

TO:	OWNER

(Name and address from Certificate of Payment)

LIENOR

(Name and address from Claim of Lien)

SURETY

(Name and 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 ,	.

Contractor

By:

Name:

Address

STATE OF

COUNTY OF

SWORN TO and subscribed before me this day of , , by (name), as (title) of (name of corporation), a (State) corporation, on behalf of the corporation. He/She [please check as applicable] /______/ is personally known to me, or has produced /______/ his/her (state) driver's license, or /______/ his/her
(type of identification) as identification.

(Signature)

(Printed Name)

NOTARY PUBLIC, STATE OF

(Commission Expiration Date)