HomeMy WebLinkAbout0421 Fefw 66i U. S. TREASURY DEPARTMENT - ~N ry~.;r?~ aevENUe seav~te Fw or„~d us. B. a«e.~+y oH~c
tREV. &67) CERTii1CATE Oi iELEASE 8F fEDFR~I' TAX'IfEN fKfe ~KO aE~atQE
' DISTRICT SEi{IAl NO. ST.UIC1~. ~~TY F~
ltOCEk POITMS
1 Mrebr c~rtify thot os fo ths Foilowing-nomtd tox CLERR CiRCINT COIIRT
poy~t the reQuirem~nts of S~ctioo RECORO YEF.~FIEO~
' 6325(0), Internol Revenue Code, hove been sotisiisd w;th ~espect to tl~e tor~s enu-
, m~rotsd b~low, toyether writh oll statutory udd:tiu~s povid~d by Section 6321; ond a S"T AH ~11
thot th~ (ien for sucl+ to:ss and statuto~y oAditior?s Iws thirebr been r~l~osed. The
proper oific~r in the o(fice whsn no?ict of int~rnol revenw toz lieo wos filed on
.Tt~nnt~ ~'j' ,~qjl ,~s hereby authwiud to make nolotion
' on his books to show the rsleoa• of soid lier., i~sofor os the li~n ~~lotes to tM ~~~q
followiny tox~s_
NAME OF TAXPAYER
~l31#r 3. t~
~ESIDENCE
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CLASS OF TAX UNPAID BALANCE
(Tox R~twn Fwm No.) PERIOD ENDED ASSESSMENT DATE b fDENTIFYING NUMBER OF ASSESSMENT
(o) (b) (c ) (d ) (e )
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lfl4o 1~•~*b~! ~i-43-7~ a'!l-~-~3 7L.~'lS.S~
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,
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~ PLACE OF F1~lNG
~ ~elc, C3lwit Cwt
~ ~aiat L~d~ TaT"~ s 1.~'9S•S'~
tart tl,w~. tisrl~a
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~ ~ i TN ESS my hand ot Jacksonville } r^7 or~ ~a , on ri,~ s,
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+.he 2t1c3 day cf J~ne ,1STl
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~ S!GNATURE TITLE
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_ _ V M I,erris Acting Chief, Special ~rocedures Staff -
~ (NflTE: Ce.tiiicm~ oF o(~~cer ou:F,ari:ed y lo.v to ~o!• ackno.vledy~nems ~s not essent;o! .o ~n~ roi:d~rr of No~;c~ of F•d•.al Ta, L~~~ G.CaA.
25119, C.B. 195d51, 125.)
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PART 3--To be used for recording purposes
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