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Fwm 668 OEMRTYENT OF TNE TREASURY-INTERNAI REVENUE SENViCE For Unt~ona/ Use By Reico~ding O//ite
(REV. 12-74) NOTICE OF FEDERAL TAX l1EN U~IDER IMTERNAL REVEMUE LAYVS
DISTRICT SERIAL NUMBER
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Pursuant to the provisions of Sections 6321. 6322, and 6323 of the Internal Revenue 1~~~,Q,~A~ ~;~~CQ~ QE~ ~ ;
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Code, notice is hereby given that there have been ~sessed under the Internal Revenue laws 1f~~f R P4~~A~~
of the United States against the.following-named taxpayer, taxes (including interest and ,~CGR~ K CIR~UIT ~O~RT 3
penalties) which after demand for payment thereof remain unpaid, and that by vi~tue of y~G~F~~~•...~..~.~.~ ~
the above•mentioned statutes the amount of said taxes, together with penalties, interest, ;
and costs that may accxue in addition thereto, is a lien in favor of the United States upon
all property and rights to property be{onging to said taxpayer. ;
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NAME OF TAXPAYER 3~~~n f.
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RESIDENCE
520 ~t . 26tr~ st . .
r^t, rierce, F~L 33i:50 -
f ~ UNPA~D BALANCE ~
KINO OF TAX TAX PERIOD ENDEO DATE OF ASSESSMENT IDENTIFYING NUMBER OF ASSESSMENT ;
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~ 22°o a_~-~~-7~: or-3~-?5 5?-1Z~~~7~7 3a3.t~1;
~ 22;0 0'-3~-?~ 3'~-30-7~ ~°-1~;5~5:~7 273.2':~
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~ PLACE OF FILING ~yer'~ oi ~~r:.;.:i~ Co;;u ~
~ :i ~ . yacie ~~oa:;,;~ TOTAL $ ~v1 •
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~ WITNESS my hand at ~'iez'ce, : L , on this,
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~ the ~~day of ~ u.*iuar~,~ . ~g 7t~ .
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SIGNAT TITLE
i?eve:.•ae Cf£~cer
~ (NOTE: Certiticete of of/icer authorired by law to takt scknowledgments is not essential to the vatidity Of Notice of F~deraf Tsz Lisn G.C.M.
~ 26419. C.B. i9S0 1, 125.) ~ ~
~ PART 1- To be retained 6y recording o!lice ~~t ~
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