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City of Centerville <br /> 1880 Main Street <br /> Centerviffe Centerville, MN 55038 <br /> 'I':t�rfilydr;at <br /> Veri,fled CZaim I 'Y ✓ <br /> Claim of: 4- Z Goigec 4re <br /> Ll <br /> Amount: <br /> Address: <br /> City, State, Zip l ✓ ' ` �r �`� " <br /> Dated: Z Z-- <br /> Approved: <br /> J declare under the penalties of perjury that 1 am the claimant making the within <br /> claim and that the some is just and true;that the money therein changed was <br /> actually paid for the purposes therein stated;that the property therein changed <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 randared <br /> and were of the value therein charged,'that the fees therein charged are oftrcial <br /> and are such as are allowed by law;and that no part of said Gl id. <br /> Signature of Claimant <br /> Date: 2 <br /> Date Activity Distribution Amount Total Acct.No. <br /> Totals <br /> �0 <br />