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F«m 668 ~r~rrt oF n+E nEwwe+r-a~~u . For op~wwl th. er R.~o?dmy or6o.
; ~aEV i-~o~ ~ CE~i'~iCAiE OF RdEAN OF ~DBtAI TAX t!H! f1~ q ~?b4 aE
DISTRICT SERULL NtJMBER ~T, UC+E G 1~
, 26iso3 azi7 p22o7 ~ ~
1 hereby ce~nfy that as ro the followin9-named taxpayer the roqu~remena of Seaion
6325(a), i~lernal Reve~us Code, hove been satisfied with resped ro the taxes aw- ! ~ ~
merated below, together with cll statutory additions provided by Ssction 6321; ond ~ ~R~~~~~
Hat h,e ~ie~ for wch taxes a~a st~niron? additi«~s tws tl~eby been re~eo~d. t1~e 9
~ oA'ioer ' ihe ofF'ioe wi~e~~ f internol reMenue tax lieo was filed on
' ~gw t 2~ , l q 7'~ ~ n hereby avtFwrized to mdce notation '
, on his books ro show the rdeose of said lien, insofar as the lien relates to the fdlaw~-
ing taxes.
NMAE OF TAXPNYHt
~
~ RESlDB~KE
~ ~
UNP/UD BALANCE
' KIND OF UX UX PERIUD END~ ASSESSMENT DAh IDBJT1FlfING NUMBBt OF ASSESSMENT
I Ial Ib1 k) Idl le1
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Y
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y
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3
~g
3
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3:
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~ ' ~cE oF Flur~c
_ C1~C~ ~t ~t TOTAL S j~~
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~ WITNESS my hand ot Jacksom?ille, F1oTida , on tfiis,
r~` the 3rd ~r of December ~ 9 73
,
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~ SIGNATUR / TITLE -
~ c .C - i ~ t e~
v;
~<< Jack D t Chief, Special Procedures Staff
(NO~ Certificate of offccr outhor~zed by tow to tn4e acknowledgmenrs is not essentiol to the volid~y of Notice of Federal Tox n G C
~n 26419, C.B. i950-51, 125.~ ~1 ~
cc eCOK ~ P~6E~
~ PART 3-To be used for recordi~g purposes
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