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•f,~,,. ~ U. S: TREASIJRY DEP/1RTYENT - ~MTE~~~tEvE?niE ~v _ ' F. qw:wt us~At R.~+a.~ OrfK+
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( NAME OF TIaXPAYER - RK C~~V~~
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f Ct;A55 OF TAX f~ A ' ~ ~FUNPAID BAIAiJCE
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wITNE55 my hond ot Jackwavills, Florida
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SIGNATURE TiTLE . ' . • '
J~ck t Cbi~f, Sp~cial Proc~dur~• 8sctioa
MOT . tiite~» d~ffie~~ srth~ris~d by law to tok~ ocknw+l~dyw~nts is not ~ssemiol to th~ voliditr of Nwic~ ef F~d«el Tm~ Li~n G.C~A.
26~19, C.B. 19SOS1. 1~5.) . pb `
lART 3--Te b~ us~d for ncordin~ purpos~s " •
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