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F.,~„ ~ U. S. TREASURY DEPARTYtENT - u~tEanA~ REVENUE SERV~CE F« O~e.a.d Uw er R.cal~ oh c.
(REV. &67) MO11CE Of FEpERAI TAX ll~ll UNpER INTERNAL REYENUE LANS .
FilE9 AN6 R ~
DIS'FRICT SERIAI NO. ~T~ LUGIE COU~~~,~
J~~~~ RECORO VERI~IED
Pwsuaet to th~ provisions of S~ctions 6321, 63~~, oed 6323 oi tM Int~rnol R~w-
nw God~, notic~ is h~r~by yiv~n thot thar~ hov b~~n oss~ssed und~r th~ Int~reol
R~v~nw laws of tM Unit~d Stot~s o9oinst th~ followin9-non~d to:poy~r, toxes f~0 YAD pN G~ Zo ,
(ineludiny int~r~st ond p~ralties) which oit~r d~wond fw parm~nt ther~of r~main
unpoid, ond thot by virtw of th~ obov~-m~ntion~d stotut~s th~ amount of soid toxes, QJ~`~
toy~tF~M with p~oolti~s, iot~r~st, ond costs tiwt isoy eccrw in additioe th~r~to, is ~G~
a IiM in fava of tn~ Uni~~d Stot~s vpon oll pop~rty ond ri9hts to ~.o~..+~ ~.i~.9- RO~ER P01 RAS V
~e9 to soid taxpoy~r. C~.ERK CIRCUIT CGI~F=~~
NAME OF TAXPAYER
Robert a. dc-Blisab.th v. Hillsr
RESIDENCE - ~
P. 0. Ho: 321a5 f
ClASS OF TAX UNPAID BALANCE J
(Tox R~turn Form No.) PERIOD ENDED ASSESSMENT DATE IDENTIFYING NUMBER OF ASSESSMENT '
(o) fbl (c) . (d) (t) ~
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10~0 12"31r•68 6~6~6~--- -'~6~~~dlt~9~---
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~ PLACE OF FILING Cl8 ~C~2'Cl~tr C011Y"rr ~'r~'j~ .
s ~ ~ TOTAL i
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~ WITNESS my hand ct Wst Ptla Bueh~- ~L-~.t. , on this,.
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~ (NOTE: C~rH(ieot~ of ofiic~r ortherls~d by Imn to t~kt xknwl~dy~ents is not ~ss~m~al to tM •olid~tr of NM~e~ d F~dM~I Tox Li~n G.C~1,
~ ?6119, G.B. 195451, 115.)
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PART 1 To b~ ntain~d br r~cordin~ offic~
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