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, Fom~ 668 - . t~MttMENi oF iFiE T~EwAtk+r-1ritEi~At cEVEnUE SFStvKi For qpriono! Uu Br Rccwd~ng CMico
(r~v 1-70~ CERTi~UTE OF REIEASE 0~ FEDBtAI TAX L~N ~{~~ol~ CQ '
DISTRICT SERIAL NUMBER
245130 B20 P2220 04~RK CI
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I hereby certify ihot as to the following-named taxpayer the requirements of Section C~~'n Y~:••FI D
6325(a). Internal Reve~ue Code, have been saiisfied with respect to the toxes enu- ?
mefoted below, together with all statutory odditions provided by Section 6321; ond ~ 12 s~ PN 13
that the lien for such taxes and srotutory addfions has thereby been releosed. The ~~C~c •
proper olFcer in the off'ice where notice of iMeroal revenue tax lien was 61ed on a) 0
.Ianug ~ , 19~3.., is hereby authorized to rnoke notafion
on his books to show the release of soid lien, iraofar as the lien relates to the follow-
ing taxes.
NAME OF TAXPAYER ~ ~ -
l~M~ ~ji~ ! ~ Z~
RESIDEPKE
1'~. ti~j~~~3~i~
UNPAID BAUWCE
KIN~ OF TAX TAX PERIOD ENDED ASSESSMENT DATE IDENTIFYING NUMBER OF ASSESSMENT
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WITNESS my hand ot Jacksonville, Florida , on this,
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t~::: the lst ~y of Februarv , 19 73
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OR
~ SIGNATURE / TITLE
\ ~Dllrliit ~ pP~~j,~l Ptnroc~~~rB~ Staff
(NOTE: Ce?tifi e a officer by low to take ackr?owledgments is not essentiol to rhe volidity of Notice of feduol Tax Lien G.C.M.
26419, C.B. 95f1~51, 125.j
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PART 4-To be wtained by SPS
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