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Form 668 OEPARTMEM Of INE 7REASUYY~ITERNAI 1EVENUE SERYKE For Opr~~oral Use Ay Recad~g Olfioe
t~~.,~-~o) CERTWUTE 0~ RELEASE OF ffDBtAI TAX t~ti ST_ iuc~c couNtr Fi~
DISTRICT SERIAL NUMBER ROCc'R ?,~ITRtS
~~ys ziza~ ai94 p770 ~tE~~ c;,cu~7 cavar~~
Co~C vfa~~~ED
1 herebr certify that os to the folbwing-nomed ta~cpoyer the requiremenis of Sec~ion
6325(a), Internol Revenue Code, have bcen sotisfied with respect to the tazes e~v- 1,~ 59 P~T3
meroted below, together w~rh al! statutory additwns provided by Secfion 6321; ond ~ 1 M
thot ihe lien for such toxes und stotutory c~ditior?s hos thereby been releosed. The
, proQeri;~ in the oH'ice where notic~ of internol revenue tax lien wos filed on
.~Il , 1~ ~ , is hereby aufhorized fo ~ake notation ~L~Q~~
on h+s books to show the release of wid lien, insofar os the lien relotes to the follow- V~7
ing toxes,
NAME OF 7AXPAYER .
~.u f ~ o~.d. s syr. ~ .
RESIDENCE
~ ~Z ~
~ ~
UNPAID BALANCE
~ KlNO OF TAX TAX PERlOD ENDED ASSESSMENT DA~E IDENTIFYING NUMBER OF ASSESSMENT
(°1 (~1 kl ld1 le)
lali ~worr ~i•3y6~ ~,}•7r 1f~ !i !!i! i iLN
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PLACE OF FIIING
C~~ ~Li TOTAL s a~~
st. ~1! Ii1~rt~
wt tl..~r._ t1~e~.
WlTNESS my hand ot Jacksonvilla, ~lorida , on this,
lst tiovember 73 -
the day of , 19
SIGNATURE `!~/%!%!/6l~/!'~i Tl
Jac ant Chief, Special Procedur~a Statf
(N . Certificate of ofRcer outhori.ed by law to to~e acKnowle~~gmen;s is no1 essenlial to the vo~~d~ty of Notice of federol Toz tien G.C.t~l,
26 9, C.B. 1950-51, 125.E
CC
PART 3-To be used for recording purposes