HomeMy WebLinkAbout0974 Fom1 668 oEPA[TMEPtt OF TNE nIE~W1RY~NTERruI REY~Ni1E SElYICE For Opfioral lhe BY Racordng Ol6cs
(REV. 1-70) C~T~A~ ~f ~ T~ ~ ~~Q
DISTRI T SERIAI NUMBER Er • _
218 21~ Bl P2 ~L• t C~A~ c
~ t heroby certi~? that as to tfie following-named Mxpayer the requiremenls of Section REC , IKRlPI
' 6325(a}, Internal Revenue Code, have been sofisRed with respect to the taoces enu-
merated below, togeMicr with oll statutory additions provided by Secfion 6321; ond !
tlwt iha (ieo for such roxes and statutory odditions has N~ereby been released. The
proper offxer in the ol~'ice whe~e notics of internal revenue tax lien was filed on
November 11~, 19_.31, is hereby authorized to iriake nototion ~~~v~~
on his books to show the release of soid lien, iosofar as the lien relota ro the follow-
. ing taxes.
NAME OF T/1XPAYER ~ ~
! RESIDENCE ,~'sMr
. ~~Ma
UNPAID BALANCE
~ KINO OF TAX TAX PERIOD ENQED ASSESSMENT DATE tDENTIFYING NUMBER OF ASSESSMENT
~ - (a) (b) Id) (e)
' ~ }~L`~ T~~"~ ~
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~ PIACE OF FILING ~ ~S
w : ~ j~~ Q~~ TOTAL s
~ ' t~ ~s ~i~
a
~ WITNES$ my hand at Jacksonvill,e, Flarida , on th~s,
= ~~~200 97~
~ the~doy of NIa~`cb , 19.77
w~
SIGNATURE TITLE
Jack Dtu~~pt Chief, ~ecial Procec~res Staff
;i: (NOTE: Cer cate of er authorized by law to toke ocknowledgme~h n not essent~al to fhe volidihr of Nohce of Federol Tax lie~ G.C.M.
_ ?6~119, . 1950 , 125.~
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