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STATE OF FLORIDA ~
FOC FORM UCT-te U~PARTMENT OF COMMFRGE
IREV. 7/73)
UIVISION OF EMPLOYNENT SF.CUNITY ~
TALLAHASSEE 32304 Ac~ount No. '~185062
Lien No. 5-9126
NOTICE OF TAX LIEN
Pursuant co the pruvisions of Sf-ction 443.15 (i) (a), FloriJa Statucrs, knonn as thc Flo~ida Un-
emplo}•ment Compensation lav?~ notice is hereby given that there have betn assesse~, pursuant to the
provisions oi said lav?, aRainst A1~CE H. Chavers
A A s Co fee Shop
917 Avenue D
~Ft. Pierce, Florida 33450
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an "emplu~er" liabie ior the pa~~ment of cuntributions to the 1,-n~•mplo~•ment Compensati.~n Fun.~ o(
Florida, pursuant tu thr pro~~isions of sai~~ lak, the sum oi 5 30.10 corerinK thr folloRin~
contributiuns, incerest an.l prnalties, ~~•6ich altcr ~lemand fur pacnzrnt ehrreof rrmain unpai~, am1
thut by~ .~ircur of thr abuti•r m~ntioncd law' thc amount u[ said contributiuns !taxcsi, cogcchcr «•ith :
penalties, intrrc•st, aml cotits that may~ accruc in addition thcrrco, consticutr ~ lirn in f i~-ur .~f State of ~
Floriu'a lkpartment of (:ommerceupon thc titlr tu and interest, n•hcthrr (cRai or ryuitablr, in any- rcal ;
property, chau~is rral, ur pcrsonal propcrty uf said emplo~~er.
j Pc::~ds for nhich contributians, iRterest, and penalties haee becn .tstie~tir~l, arn! ihr amounts
~ thcreof, am as follow•s:
i
i
~ ~NTEREST THROUGH
~ PERIOD CONTRIBUTIONS p PENALTIES
O
1
~ I 3/73 5 00
~ 1/75 9 90 20 10 00
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I f p ti~.: ~~~:tiK~fB ~
S -1~1~~`- :~vMti iL~• ~
k'v',i_ ?i:!TAD~
C f~~ G. C'J1? C9U~ !
~fr_. •Rt, y~~;';L~...~.•"'~ I
~ 13 IO ~N' 15 ~
~ ~ ~ ~
~ ~
~ ; i Service F e ~ 5.00 ~a , ~
~ ' ~
~ ; ; !
~ ~ TOTAL ~ 9 9O 2O 1S OO
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~ WITNESS THE OFi~IC1AL SEAL OF THE STATE OF FLORIDA DEPART~fEYT ON CO~1~tERCE ~
~ anJ the hand of lhe Director o( the Di~•ision of Emplo~~ment Securih Ihereof, at Tallahassee, Florida, ;
this 8 day of September , A. U. 19 75 ;
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, ST:~TE OE FLORIUa ~
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~ - = . DEP~RTIIE\T OF (:O~1~fENCF
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'Fh'ts instrum~nt. ~repared b~ :
T- ~ ,
~r ~~IVr~la~ne M~Z1~_______ O~~EC`OR,D+V~S~ON Of
~ Dep~rlmen[ ot (:ommrr~~ 80^Y~~~ EyPLOYMENT SECURITY
Ca1dw~U tild~c.. Tallaha..r~•. Flr. ur~
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