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~.F U. S. TREASURY DEPARTMENT - IIITERNAL REVENUE SERVKE Fv ~ R~c~rJ+~ ON;n t
c~,?. ~:-a~? NOTICE OF iEOERAI TAX t1E11 UN~ER INTERNAI RErE1WE LAwS . uo~E co~
DISTRICT SERIAL NO. CL R~ClRCa
~T
RECORO VERi~~~p,r~
Pursuant to tM provisions oi S~ctioes 6321, 6322, and 6323 of th~ Int~rnal R~v~- . ~
nw Cod~, notic• is Mr~by yivsn thot ther~ hov~ be~n ossess~d w~d~r the int~mal
Revenue kws of the Unit~d Swt~s oyainst tM foilowiny-non+td tdxpoy~r, tax~s
(ineludiny iet~r~st and p~nolti~s) w6ich ofhr d~~aond (or poym~ot tMrtof ~enain
unpoid, ond ttwt by virtu~ of the cbove-nNntioMd stotul~s the omount of soid tax~s,
to4Nh~r with p~nulti~s, int~rtst, ond costs tFwt nwr occrw in oddition tM~~to, is
o(i~n in fovw of ths Unit~d Stotes upon oll prop~rtp ond ri9hts to propsrty Mloe~-
in9 to soid toxpoy~r.
NAME OF TAXPAYER
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RESIDENCE
.
ps~e'O~ ?laeida
~ UNPAID BALANCE
TAX FORM NUMBER PERIOD ENDEO ASSESSMENT DATE IDENTIFYING NUMBER OF ASSESSMENT
(o) ~b) (c) (d)
; ](~~0 12-~~k 6•Y-6~ Z6~"~al~h 1l~5~~'l
i .
Fi.ACE OF FILING
C~'k~ C3i~+01~1tr OOI~lt' TOTAL S 1~~~:'f
L~si~ Cw~1~
lL~Y+o~ ~l~l~da
NOTICE OF fEDERAL TAX LIEN REfILIN6 ~.7_~
IRS SERIAL NUMBER RECORDER'S IDENTIFICATION NO.
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NOTICE FILE~ WITH_~e~ ~~tr ~~~-f. ~ 0l~.~ DATE
~ TAXPAIIER'S ADDRESS
~ (If d' o above) -
•
~ SIGNATURE
WRNESS mr hand at ~ti p~~ n~'1~~ , on this,
the ~
-da~r of x0!!~~' . 19-Q~--
SIGNATURE ~ J a ~1 TITIE -
(NOTE: CertificaM of ofRcer authorized by low to roke acknawledyments is no1 essenrial to the voliditp of Notice of federal Tax lien
G.C.M. 26419, C.d. 1950-1. 125.}
PART 1 To be rNoi~~d br recording offic~
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