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t~xm 668 DEMRTMENT OF TNE i~EASURY-MEW/~l lEVENUE S~VICE For Oplionol U~e SY R~co?di+~p Q16c*
j~N ~-~o~ CERT~iCATE OF REtEA~ OF FEDQAI TAX UEN o EgRE~oR
DISTRlCT - SERIAIy ER auN~1r
21757~ B]: QtERR CIitCUiT COY111~
1 he~eby ce~;fy Mwt os ro rhe fdlowing-~omad roxpoye~ N~e rec~uirements of Section ~OR01?ERI~IEOr.....~..
' 6325(a), Internal Reveoue Code, have been sotisRed with respect to fhe taxa enu- ~ r~ ~1 u~~~~
merated below, logether with all statutory odditions provided bp Section 6321; ond
' Nwt the lien for wch taxes and stotubry additions hos thereby been released. The
' proper ofi'icer in the of~'ice whero notica of internal revenue rox lien was filed on
QQtnhwr , 19~1_, is hareby outhorized to ~rioke notot'an jl~`~Q
on his books to show the reiease of soid lien, insofar os the lien relates to the follow-
ing to~ces.
NAME OF TAXPAYER ~
, ~ ~
, RESIDENCE
3~11 ~~~i~r ~i~lt
rl+~a+M~ ~'i~a~l~~1~!
UNPAID BAIANCE
KIND OF TAX TAX PERIOD ENDED ASSESSMENT DATE IDENTIFYING NUMBER OF ASSESSMENT
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$
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~ PLACE OF FILING ~ ~t
~ ~ TOTAL s 3~~
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W/iTNESS my hond at `j~~0~~~~ ~~~e , on this,
- the ~day of MarCh , 19~?
Ys
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~:a SIGNATURE " TITLE 88R!c ~ f.ACf
Jack Dur Ch3sf cial Procedures Staff
{NOTE: Cert e of ca outhor~2ed by low to toke ocknowledgmenn is not essentiol ro the rol,d~ty of Notice of Fedaol Tox lier? G.C:M.
26119, C. . 1 - l, 125.)
PART 3-To b~ used for recordin9 purposes ss
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