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Fen„ bbs U. 5. TREASURY ~EPARTMENT - ~NTEaN~~ REvEHUE SEav~CE fo. OW,o,wl Use Br R««d~~y 0++'c.
iREV~. 8-67T CERTIfiCATE OF RELEASE OF ffDERAI TAX l1EM
OISTRICT SERIAL N0. 'FII.ED AI?IO~RE~O~~~.,,
~r~ ST. l.UC1E COUN Y. i~LA.`=
REi 0 VFRIF±FO -
I herebr ee?tify thot as tc the Following•nom~d toxpoyer the reQu'uem~nts of Section ~~~(~Q
6325(0), Internol Revenue Code, have bean sotisfied with respect to the toxes enu- v~
m~roted b~lew, together with ol! stotuto~y odditions provided by Section 6321; ond 10 OCT ~ ' O~
that the lien for sueh toxes ond statutory edditions hos shereby been r~leos~~. The ~
propsr of(icer in the office whers notice of inte~nol revenue toz lien wos filed on L
OCt~b@P 14~ , 1~~ is hereby authorized to make nototion
on his books to show the release of said lien, insofar os thr lie~ relotes to the ROG~R ~~T S
Eoiiow~~9 ~a:.:. CLERK CIRCUIT COURT`
NAME OF TAXPAYER
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RESIDENCE
= 3! H0~ ~f ~"~i n~'!"O~~ ~1~1~~~1,~
CLASS OF TAX UNPAID BALANCE
iTox Return Form No.) PERIOD ENDED ASSESSMENT DATE IDENTIFYING NUMBER OF ASSESSMENT
(01 (b ) (c 1 (d 1 (e 1
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3
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~ PLACE OF FIUNG ~
~ ~ TOTAL ~ 3
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~ wITNESS my hmd ot Jacksonville~ Florida , on ~h~s,
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_dvy of October ,19 7U
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~ ~IGNATURE TITLE
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~"s. fNOTE: C~r~~ficor~ f'c~r outhorf:~d br low ro to e ocknowledymen~s ~s ~ot e se.+t~ol~o ~ valid~o~ No~ic~ o~ •~ro Toa L~e~ G.CJd.
~ 26119, C.B. 195P: , 1 ~
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~ PART ~To be used for recording pGrrpose~ ' s~
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