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fen~ 66a tl. S. TREASURY OEPARTMENT • lNTERNwI REYENUE SERVICE Fa qr~,a~l l?se 8r Rec~rl.M p~ r~ ~
(REV. &67) MOTICE Oi iEDERAI TAX LIEM UNOER INTERNAI REYENUE IAwS ~lE p ~g
D15TRICT SERIAL NO. :~•R~
~C~~TY~,
?nr,Ii,n~~~T?'~_?,'; CtERK C~RCYIt ~~COj11~T ~
Pursuant to tM provisions of S~ctioos 6321, 63Z2, ond 6323 of th~ Int~rrwl R~v~. IIEC0110 Ytlt~?IEp.~~~~~~~
nw Cod~, notic~ is hs~~by yiven thot th~r~ Iwve 6e~n ossess~d under fh~ Int~rnal
R~vMUe bws of th~ Uoit~d Stotes apoinsf tht Io!lowiny-noen~d toapoy~r, ~ox~s
(i~cludinp int~r~st and p*nolti~s) which oit~r d~wand fu poya~ent th~r~of remain
unpoid, and thot by virtu~ of th~ obovs-a~ntion~d stotut~s tb~ omount of soid tox~s,
toy~th~r with p~nolties, int~r~st, and cosfs tlat tsoy occrw in oddition t{wr~to, is c
a ii~n in favor of ihs United Stotes upon al! Otope~ty and riyhts to p~opertr b~lony. V ,
inp to said taxpoy~r.
NAh1E OF TAXPAYER
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RESIOENCE ~ /c , :
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CIASS OF TAX ~ UNPA10 BALANCE
(Tox R~turn Form No.) PERIOD ENDED ASSESSMENT DATE IDENTIFYING NUMBER OF ASSESSMENT
(a ) (b) (c ) (d ) (t )
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