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o~cr~r of 1HE r~ws~,Rr-.~e~ +rEVe~x,e fo. owionor ,b. er R.oo~rdr~p oAGa.
' ~ol tRifKATE Of R~ASE Of iE~AI TAX ~~~o ~f
! OtSntICT SERIAi. NUMBER ~T. L1iC~E C+91fM
~ 2 7 s196 ?1341 ~t~
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! 1 hereby certify thot os ro the folbwing-nomsd roxpayer ths roquireme~ls of Sectwn
6325(0~, I~ternol Rev~enue Code, have bsen s~ed with ~espetl to fhs taocas erw- ~
~ meroted below, togetf~er with all statutory ad~tions provided by Ssction 6321: ~d
~ that M~e liea for svch tu~ces and slatutory odditiau hos t}iereby besn releosed. Ths
proper ofFicer in~th~~f~'icrs t~e nofics internal reva~ue tax lien was filsd on I~iV~I~iV
, i~ 19 , is henbp auHwrized to didce notatan
on his twoks to show the reteose of soid (ien. i~of~ ~ the lien raiates to the fotbw- .
i~p tmoes. :
+ N/1ME OF TAXPAYHt
i ~~~~~~~r
i -
; RESIOENCE '
j~ ] ~ i`
;
~ 1't+ !!~M? ~ '
~
UNPAlD dAlAtrCE
; KIND OF T/1X Ti1X rERIOD Et~O~ ASSESSMENT ~ IOENnFlfING NUMBElt OF ASSESSMENT
; a~ ro~ k~ w~ a~ .
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; OF FfUNG -
€ Ct~r~t, Cie+~uit C.outt TOTAL =
; St. Luc`a. CO~N~ty
; ~art Pisros. fbrid~ -
i
' vti~TtvESS ha~d ar Jackaaoville, Florida
~^Y , on Ihis,
F
~
; the 2~ day of ~Y , 19 A
fl
~ . 600K PACf
= S!GNATIHtE TI~IE
~ - a u~ .c~ Q
; J Duraat Chi~f, 3pscial procedurss Staif
(tJU C,f,cute of ofRce~ outhor,:ed by tow to take ocknow{edymenfs ~s na sueM~d b ri,. vd~dar of Nw~ce of F.derd Tox lan G.C.M.
' ?b419, .B. 1950-51, 125 ~
€
g PART 3-To bo us~d fw ncordinp purpot~s
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