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<br /> <br />ervif[e <br /> <br />City of Centerville <br />1880 Main Street <br />Centerville, MN 55038 <br /> <br />Verified Claim <br /> <br />Claim of: <br /> <br />~j71-e.af/~ <br />$ /0 (/{Ja . eQ. <br /> <br />Amount: <br />y, <br /> <br />Warrant No. <br /> <br />Vendor No. <br /> <br />Dated: <br /> <br />rrvv-cf\ (0 . ~op+ . <br />, <br /> <br />Approved: <br /> <br />""~';'. <br /> <br />I deClare undet the panaffias of perjury that I am the claimant making the within- <br />e/aim and ff!!J( the sattie is just .and true; that the money therein. charged was <br />actually paid fiir ihe purposes /herein staled; that the property therein chaflJed <br />was actuanld~iive'ted 9r iJsed for the puipOses therein stated, ah'd was oiihe <br />ValUe th<ireMchai(Jed; that the selVices /herelh chafiJed we'" actUallY rel1rJetfid <br />and wero of the, vallie theroln charged; that the fees /heroin charged a'" off/cW <br />. and are suCh as .iiiB altowed by law; ahd that no part of said claiiil has beeh fieid, <br /> <br />Signature of Claimant <br /> <br />. Date: <br /> <br /> , <br />Distribution . . Amount <br />!(J{... I'I TI / ~ c/q (') <br /> . <br /> . <br />I <br />