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~ -~F~ ~ . U. S. TREASURY DEPARTMENT - INtERN~~ REVENUE SERVICE ( Fa qr~~o..el ~k 8r R«ar1..y 01(~n '
! (REV. 8-b7~ CERTIfICATE ~ REIEASE OkffQERAI T~X UEN f--
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OISTR{CT SERIAL NO. 5~,~~IE C01l~iT
188658 8182 P116o aocER Pat~u?a
; 1 hereby certi(y tho~ os to th~ followin9.nam~d toxpoy~~ the r~qui~~m~nts o~ Sec~~a+ ECORO YENI~f E~ ~~T
63Z5(a), Internol Reveou~ Cod~. hove b~~n suti3fi~d w:th respect to th~ tox~s ceu-
mtrottd btlow, to9~th~r with oll stotuto~r elditions provided by Section 6321; ond ~~g ~ a~ ~~Tt
that the lien fw such ta:es ond stotvtwr odditians hos the.eby beeo ?~I~as~d. Th~ ~y
i pop~r oNicer in the o(kc~ wh~r~ noti,c,•' nof int~reol rsvenue taX lien was f:l~d on ~~i
J~~ 21~ , 1~r~. ;s I+~nbr authwi:~d to nok~ nototion
on his books to show th~ rebos• of said lien, inso(ar os the li~n r~lotes to th~
followi~y taxts.
NAME OF TA~(PAYER
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RESIDENCE -
~ Z~ ~~~r 'a'~ M. ri~w~ !L.•~9o .
CE.ASS OF TAl( UNPAID BALANCE
, iTox Return Form No.) PERI00 ENDED ASSESSMENT DATE IDENTIFYING NUMBER OF ASS:SSMENT
~ (o) ib) (c1 (d) ~s)
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LACE OF F LING ~ Qi~it
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~ wiTNESS my ha,d or Jacksonville~ Fla~ida on ~h;s,.
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tho~h_day of Sentember ,19~1
SIGNATURE TITLE :
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(NOTE: Cer~~fieon d ofli e is low ?o fek~ ee4ner.l~dqrwsnrs is not ~sa~~r~al to ~M ~ol~d~~y e/ Na~e• ~i F~d~el t~s L~:~ G.C.M.
I6119, C.B. 193051, 1 ~
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~ART 3-To b~ usfd fan c~onlinq purpos~s
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