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<br /> <br />ervi[[e <br /> <br />City of Centerville <br />1880 Main Street <br />Centerville, MN 55038 <br /> <br />Verified Claim <br /> <br />Claim of: <br /> <br />;//r' ~HM <br />$ ~ .;)/tJ, 00 <br /> <br />Amount: <br /> <br />Warrant No. <br /> <br />Vendor No. <br /> <br />Dated: <br /> <br />5;;.5'4~ <br /> <br />, / <br /> <br />Approved: <br /> <br />I declare under the penalties of perjury that I am the claimant making the within <br />claim and that the same is just and true; that the money therein charged was <br />actually paid for the purposes therein stated; that the property therein charged <br />was actually delivered or used for the purposes therein stated, and was of the <br />value therein charged; that the services therein charged were actually rendered <br />and were of the value therein charged; that the fees therein charged are official <br />and are such as are allowed by law; and that no part of said claim has been paid. <br /> <br />Signature of Claimant <br /> <br />Date: <br /> <br />Distribution <br /> <br />Amount <br /> <br /> <br /> <br />2; <br />