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Richard Lee Prlaus and/or Brent Wllllani Prf- <br />DBA R & B Holding Company <br />^32 Midland Bank Building <br />STATEMEHT - PENALTY DUE $200 .00 <br />tax parcel 3B-41331-2300 as reeeivH <br />•nd 19 July. 1978 <br />• <br />I daclara under the penaltiee of perjury that I aa <br />Treaaurer <br />THtlJ“ ®«le. and nM of a™ i( el.l« It by . „r eorp.) <br />axeaiined aald clal. and that tha ««a i, ju.t and true; that the <br />■onay therln charged uae actually paid for the purpoaee therein <br />stated; that the property therein charged was actually delivered <br />or used for the purposes therein stated, and %»as of the value <br />therein charged; that the services therein charged; that the fees <br />therein charged are official and are such as are allowed by law; <br />and that no part of said claim has been paid. <br />Signature of Clni—n» <br />TiM effect of this verification shall be the same as if subscribed <br />6?