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{REV. NOY. 1961 ~ CERTI~iCATE QF RELEASE OE FEDER~L TAX ttEN ~a~E~~l~'
~Formerly Form 669~ (io M w~d ro R~i~as~ Te: U~ns vnMr S~cfton 634~t1l, I.R.C. ot 19541
; OISTRICT .
F SERIAL MUMBER
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~ i hereb certif that as to the foilowin named fvx
y y g- puyer the requirements of Section 6325ta), Interno!
Revenve Code of i 954, have been satisfied with resp~ct to the taxes envmerated below, together with
a(I statutory a~clditiGns provided by Sectio~ 6~321; and that the lien for such toxes and stc~tutory additions
has thereby been released. he proper of~icer in the offKe where notice of intern~tl revenue tax lien
was filed on ~7~ 1~ , 19_~, is hereby authorized to make notation on his books to show
the release of said lien, insc~far as the lie~ relates to the following taxes.
NAME OF TAXPAYER
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~ RESIDENCE OR PLACE OF BUSINE55
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' ~ AMO'JNT OF
iYPE ~ 7RX AND PERIOD ASSE55MEM DATE REFERENCE NO, a5SES5MEMT
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f ROGER f~U1 i kkS, CLERK ~
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PIACE OF FILHVG - ~
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WITNES,S my hand at Jacksotivill.e, Florida _ , on tl~is,
the_ 20 day of~ AuPUSt ~q 6~
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DISTRICT DIRECTOR OF I":TERNAL R ENUE 6Y (Siqrxstvnj 7fTtE Chief, $~76C
Laurie W. Tornlinson F'r~cedur~s Secti.on
4NOTE: Cenificot~ OI OfFKN OVfILAI12!{~ ~Y IOW t0 10ICE OCIS fadgmenh ia nd essential to ths wiiditY of Htiis documeM. G.C.M. 26/19, =.B. 1lDfl-~, 1~5.?
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