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Fe?s 66a U. S. TREASURY DEPARTMENT - INTERNAL REVENUE SERVi[E Fw OM,onJ Ua er R.~ad~ dl~c• ;
(REV. 8-67) NOTICE Of fEDERAI TAX IIEN UNDER INTERNAL REYENUE LAwS f,j~o ~N4 a Q~~
DISTRICT SERIAL NO. iT.11101E G~~~rLA, ~
~T;~ru;;~~?~,I,~ ROQEN POtTRA: ~
CIERR CtRC111T C01M1'
Pursuont to th~ p?ovisia+s ot S~ctions 6321, 63Y2, ond 6323 of the Int~rnal Rev~- RECO~O Y~R~f~O
nw Code, notic~ is 6~reby 9iv~n that th~r~ hov b~en oss~sssd ueder ths Inte~no) ~
R~v~nwe lows of the Unit~d S?ot~s aqoinst th~ followinp-ncrosd toxpoyer, tox~s ~~3
(lncludiny iot~rsst and p~nolti~s) which ofttr dtaand for poyen~nt thsr~of r~moi~
unpoid, ond thot by vi~tw of th~ obov~•m~~tioned stotut~s th~ amount ol said tox~s,
toy~th~r with psrwlti~s, intsr~st, ond costs thot mey occrue in oddition tM~e~o, is 2 ~y
e li~n in favor of thc United Statss upon ol) property and riyhts to property balonp- I
iny to soid toxpoy~r.
NAME OF TAXPAYER _
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RESIDENCE r ~ ~q~5
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CLASS OF TAX UNPA10 BALANCE
(To~c R~turn Form No.) PERIOD ENDED ASSESSMENT DATE IDENTIFYING NUMBER OF ASSESSMENT
(o) (b) (c) (d) (e1
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WITNESS my hond ot P; `~r~~ , on thi s, ~
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SIGNATURE ~ ~ TITLE _
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