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Fors 668 U. S_ TREASURY DEPARTIAENT - ~NTEaru~ REVEr+uE SERV~CE Fo. Onr~me? Us. By R«ad.aq 01f~ce
, _
(REV.8-67)
DISTRICT SERIAL NO. ~ F{ D ANO R~CORDED` _
ST. UC1E COUNTY: FLA. ~
Pursuont to th~ provisions of S~ctio~s 6321, 63Z2, and 6323 of the Internal Rer~-
~ C O R n ~8 `H~JH
nu~ Cod~, ~otice is her~br qiren thot th~r~ havw 6i~n oss~ss~d und~r the Intemol
R~venut bws of the Unittd Stotes oyoinst the (ollowin9-~omsd taxpor~r, toxe~ y Q~ • O
(includin9 int~rest and p~nolti~s) whicF~ oft~r d~nwnd fo? porment thtr~o( rema G' ' n
uopoid, aod thot br virtw of t6e abovs-m~ntioeNd statubs the omount o( soid toxes, .
to9e~h~r with p~nclti~s, int~r~st, ond costs thot moy occrue in oddition tMreto, is ~
r l::;; t~y~, a( !4!e !!!!!*4~ ~!n}~s u~n QI! ~enert~r and riehts to Qrop~rty belo~9- h~ . OITR~.S
in4 ~o said roxpoyer. RK CIRCUIT COURT.:
NAME OF TAXPAYER
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RESIDENCE
L'~~~ ~f ~ ~Z~~ ~i~~j~
CLASS OF TAX UNPAID BALANCE
(Tox Return Fwm No.) PERIOD ENDE~ ASSESSMENT DATE IDENTIFYING NUMBER OF ASSESSMENT
~ (o) ~b) <<) (d) (e)
~
k
E
~
~ 3roirD ~-31-b~ T-~5~-6! 2b1-6z-d~9 5~5•Lo
~ ,
€
5
~ +
~
f
s
~
PLACE OF FIUNG C~t ~
:N ~ TOTAL S ~j~~
~
~ ~'~r~ n+~0~~ ~i•
WITNESS my hond at ~'O" ~"s~•
~ the~_day of ~~j -,19
~
SIG ATU TITLE
, t~o~ Supanisoz
~3 OTE: C~rtiHc t (eM to~tdc~ ~cknewl~dyw~MS is nol ~ss~ntiol te tM .ol~dshr of Na~c• of F•~..el Ta: Lt•n G.CJiI.
, 26t19, ~.B. 195051. 125.) 0~ ^A s
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PART Z-To b~ nc~ipttd and retumed to th~ Intemol R~venu~ S~rviu -
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