State of
County of

Project ID:	enter text.	Project No.:	enter text.
Designation:	enter text.	Parcel No.:	enter text.
Landowner:	enter text.

I, enter text, hereby certify that all sums due to me to date from enter text for enter text in accordance with Order and Decree in Case No. enter text have been received.

Dated this	day of	,	20

This instrument was acknowledged before me on
(date)

By

(Seal)
Notary Signature Line
Notary Printed Name
Notary Public for State of
Residing at:
My Commission Expires:	/	/	20