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Form 668 DEPARTMEM Of 1}IE iREASU:+f-NTE~tAI RfVENUE SERVKE For Opliora) Use Sy Racnrd~ng
~~r. i-~oy CERTWUTE OF RELEASE OF fEDBGI TAX LffN ~~~Ep ~ND ~
DISTRICT SERIAL NUMBER ~~ER ~
21~616 ~l ~~p
YER~~~
I hereby certify thot as to tfie following-nomed taxpayer the requirements of Section REOM
6325(a~, Internol Revenus Code, have been wtisfied with respect to the toxes enu- ~~11
merated below, together with all statutory additions provided by Section 6321; and ~~6
thot the lien for such taxes and statutory additions hos the~eby been released. The
proper o!~'icer in the ofFice where notice of internal revenue tox lien was filed on
.Tnna l~~~ , 19~~, is he~eby authorized to r~iake nototion
on his books to show the release of wid lien, insofo~ as the I~en relates to the follow-
' ing taxes.
NAME OF TAXPAYER -
i~ist~i i ~ t1a~~
RESIQ~E~ ~r
a~w
~ !~t !l~rM~ 1?~ei~da. ~
; UNPAID BALANCE
j KIND OF TAX TAX PER10D ENDED ASSESSMENT DATE 1~ENTIFYING NUMBER OF ASSESSMENT
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PLACE OF FiIING
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WITNES$ my hand al " , on this,
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_ rhe 1?~:- doy of ':~:r~-~~er , 197' -
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" S~GNATURE T1TLE ~ ~
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N y errif cote of off~cer outhor:zed by law tc toke ocknowledgmen!s ~s rot essent:ul 1o the vohd~ry of Nohce of Federo! To,c Uen G.C.M.
` :a 6419, C.B. 1950-51, 125.)
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;.:y PART 3-To be used fw recarding purposes
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