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F~r,,, 6b8 U. S. TREASl/RY DEPARTMENT - v+TERH~~ REVENUE SERViCE Fa ~ 3~ , a««d, a~,:. -
(REV. 8-67~ CERTIFICATE OF REIEASE OF iEDERAI TAX l1EN
DISTRICT SERIAI NO. ~
( her~br c~rtiFy t ot os to th~ fo{lowing-~am~d toxpoyer th~ r~auir~m~~ts of S~ction
6325(0), (nt~rnol R~venu~ Cod~, hove be~.i sotis(iad with respec~ to tM tox~s enu-
m~rottd b~low, to9eth~r with all statutory odditio~s provid~d br S~ction 6321; and
thot the I~en fo~ such tox~s ond stotutwy additian: hos thsreby be~n r~l~os~d. TM ~ O~~ O~
p~op~~ officer in the offics wh~r~ ~otic of ~nt~rnol revenu~ tox ti~n wos (iltd a+
IZeCH$Al" 12~ , 19~, is her~by outhori:~d to nake norot~on / ~
on l~is books to show thc re(sose of said lie~, i~sofor as th~ li~n rtlotes to the
l.
(ollowiny toats.
NAME OF TAXPAYER ~
~ Ci • ~
RESIDENCE
Y~ u~ ~ ~ ~i~ H~'M! ~i~~
CLASS OF TAX UNPAID BALANCE
(To: Rerurn Form No.) PERI00 ENDED ASSESSMENT DATE IDENTIFYING NUMBER OF ASSESSMENT
(o ) (b ) (c ) (d l (e )
i'
~ 30i~p 3Z-3~~-6~ 6~tT~1 ~6-S~-T3~ ~j•~7
~
~
~
~
~
a
~
~
~
~
~ -
~ PLACE QF FIL~NGa~~~ C~i; ~
~ TOTAL ( S 1~~~~
K~l~w~ l3s~ I
~
,i
~
~ WtTNESS my hand at .lackse~lle ~ Fleridg , on th~ s,
~
y~ the loth doy of l~arch ,19 ?1 _ _
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SIGNATURE TITLE
~
~
Jack Dnrant ~ Chiet S cial Procedurea Staff
(NOTE: Certificott o~ offict cu ~t• b~ lo.. ro taSe oc no»~edymsnt n sent~o: to the .ol~d~~ oF Nohce o~ Fsd~rol Ta¦ ~~en G.C.M.
~ 26419, ~.g. ,QSOS,. ~~~0 241~'
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PART 3-To be us~d for recording purposes
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