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F~r ~S U. S. TREASURY ~EPARTMENT - INTEQNAI REviNUE SERVKE For Op.oivl Use 8~ R«o.d.y OH~ce '
(REV. w67) CERT1FiCATE Of REIEASE OF FEQE~AL TAX L~N F!t.E ~
DISTRICT _ SERIAL NO. Si-lUCIE COYM
; ROC~R FOITRAf
~ 1~? 0 1 Bl~l Pl CLERK C~RCt11T ~9l~~
t h~..br certifr thot os to the Eollowin9-nom~d toxpoy~~ the reQ~irem~nts of S~ction RECORO VERIF1f9
6325(0), Inr~rnal R~vtnw Code, lwvc b~~n sotisfied with r~spect to the tax~s enu- '1
~ntrot~d btlew, to9ether with oll stotutwy odditions p?ovid~d br S~ttio~ 63Z1; o~d ~
, tlwt th~ lien-t'w such toxes ond statutar cddilions Ms thtreby been r~l~as~d. The
prop~r ofiicar in th~ offics wher~ ~otice of int~.no1 revenw 1ax li~n wos filed on
DeC9mbB2' 1- ~ , 19 69 _ ii l~er~dr ourhor~:sd to moke nototioe~ ~~~1 _
on his books to sl~ow the releose of soid lien, insofor os tM lien rtla~~s to tM
followiny to~cts. ~
NAME OF TAXPAYER ~ ~
. ~ ~ ~ •
' R~SIDENCE
. ~~0
~
CIASS OF TAX UNPAID BALANCE
iTox R~tu.n Fo~m No.) PERIOD ENDEO ASSESSMENT DATE IOENTIFYING NUMBER OF ASSESSMENT
io ) (b) tc ) (d ) ie )
~ ~
i ]M~ ]9k~~ s1~.A1~.~
, - M
i ]~l.~~ ~ ~
~M li• iay~ !i
t ~ ~ ~
~ i
. /
i
~
~ ° A F FI IN
~ CE O L G
~ ~ ~1 ~e "'y' TOTAL S
~i Z~~ ~j ~I~~ ~ ~ - ~
w~TNESS my hand ar .tar_kspnvi~ ~ e, r lnri~a . , or, *h~s,
~
the_ *.F doy of .111nP ,19 ?1 _
SIGNATURE ~ TITLE .
~ ~1,^ ~ - -
v;~ ~~v~s U.•~' i L-~-' Ac~ing ~hie.f, Spec+al °rooedures Staff
- (NOTE: C~rrificot~ of oH~car o~~hor~ t~d by !owr ~o +o4e a-4na..l~dq~r,ems ~s not ~ssen~;a1 ro ~he .o1,d~sr o~ NW~c~ st F~A~.ol Toa L~~~ ~:.C.M.
26119. C.B. 19Sb51: 125.? 6~~~ ~ S3
PART 3-Ta ba us~d for retording pyrposss
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