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~Foem 661 U. S TREASURY DEfARTMB~IT . INTERIVAI REVENUE SERYICE Fer qi+krol Ow d RwarJty OMta b t
(R@V. 4-65~ , NOTICE OF fEDERAL TAX LIEN UMDER INT~tNAI. I~YQIUE LAWS ~
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DISTRICT SERIAL NUMBBt f °Z(~`~;~~ I
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Jacksanvill.e, '~la. i
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Pvnuant To tl~e provisions oi Sedicns b321, 6322, and 6323 of du Inlemal Revenue Code, '
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not;ce is here6y given that chere have been assessed undx the InMrnal Revenue inws or the
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Un'ted States ogainst the foliowing•named fozpayet, taMes ~lnciuding inhrest and ptlrwiffes) which ~ ~
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" after demand for poyment ~hereof remain unpaid, and fhet by virtue of the above•msntioned !
statutes the amount of said taxes, ?ogether with penalties, interest, aod cnste ihat rcwy atcrua ~
in addltion thereto, ia a lien in fovor of !he United State~ upon all property end rights to property ~
be'cnging to »id taxpuytr, ~
NAME 4F T/U(PAYER I
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John M~ Sample !
RESIDENCE OR PLACE 4f BUSINESS I
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Box 1~t7, Ft. Pierce~ Fla.
~~c,~ pF TpK U4PAID BAUWCE I
~fan Return Fortn tJo.~ PERIOD ENDEU A55ESSlr1EM DATE IDENTIFYING NUMBER OF H55fS5MB~R I
f a~ Ib~ ld Idl ~e1 i
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lol~p 12/31/61~ 5-26-6~ 26~-58-9029 602~71~ ~
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~.i+c~ oF ~iu?~c ~lerk, Circuit Court i
~ St. ~~.~cfe County, rora~ ; f~2.7l~
Ft. ~ierce, Florida
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WITNESS my hand at_ West PA~n ~e~ch, ~]~+r+~~_ , on thls, ,
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the Xst ~y of OCtober ,14~
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D15TRICf DIRECfOR OF INfERNAI REVBJUE 6Y nI TITI~ ~ i
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F. S. 3ctmii.dt ~ ~3mup 3upereieor ~ '
xba~s C. 4rx~ree
INOTE: Certifiearo of officw autfarind by low t~ take adcnowl~dqm~ma ii rwt ~fla! ro the valldi'ry of No1kN o( hdaal Tox LNn G.C.IA ~
14419, C.B. 1450~51, 125.?
MRl' 1-ro be rMain~d by ncordiny offfa a q 1~Q t]~ ;
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