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ForR1 GG8 OEPARTMENT OF 1HE TREASUtY-RiTE~1M REVENUE 3QVICE For OAfiono) Usf dy R~cordng OfRte
(REV. 1-70) ~~~G~ ~f ~ T~ ~
DISTRICT SEtttAl Nl1MBER f~L11C1~0 E tY
2843~?3 B2I7 F2~ ' RO~R A T i
I hereby cemfy ~hor os ro fhe foliow~~g-nortied raXpayer_the requ~~eme~n of Sechon CtEQK CIRC{p?~
; 6325{a~, Internal Revenve Code, have been satisfied with resped to the taxes enu• RECORD VEAtilEO.~.~..~..
meroted below, together with all statutory odditioru provided b~r Section 6321; and ~
that the lien for such toxes qnd statutory oddi6ons 1?os thereby bean releosed. The ~~3 ~~7 ~ T~
, pro~~t 1n the office where notice qf intemal revenue tax lien was Sled on -
Z , l9 73 , is hereby authorizad to moke notation
on his books to show the releose of said lien, insofor as the (ien ~elates to the folbw-
ing taxes.
NAME OF TAXPAYER
RESIDE
.3~30 9~eM~t t~I~M
UNPAID BALANCE
_ KIND OF TAX TAX PERIOD ENDED ASSESSMENT DATE IDO~ITIFY{NG NUMBER OF ASSESSMENT
lal ro1 t~I idl te1
2040 ?~~or~e 12•3~-'~I. $wl~?2 E~t2 4~ ~49 ~ s 2E~a.6~ti
I,0~0 2~orr~ l~~?2 ~+Z~?3 531 Od A609 1s069.2~
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PLACE OF RUNG
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; Cl~ic~ t~i~Ci~it Gbu~t TOTAI ~i I,24?.91
S+t. Luai~ Co~
' WITNE~ my hand at Jackao~rille, Florida , on th~s,
; ~e 16th of liovsber ~ 9 T3
.
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; ~G~`S ~~.~.1 i •'1~.~
` SIGNATURE ~ T1TLE
; ~ •
' Jack t ~ ~ "
Chiat, 8 ecial Procedures Staff
~ (NOIE: ' cote of officer authorized by {cw to toke ocknowledgrnenfs is nd essentiof to the volidiy of Notice of Federd Taz Lien G.C.M
; 26419, . . 1950-S1, 125.)
PART 3-To b~ used foc ncordinp pu~pos~s cc