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~ fonn 668 . oe~1RT~Nt oF n+E r~fwstlAr-t~rtElaw. eEVENUE sHMCE ior opJo~wl u,. y R.oor+d~p OIRo.
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1 hereby ceiiifp thot os ro.1he followirp-nomd taxpayer ths roquiremanis of Section
d325fo1 Inlsmal ReMenue Ce~1., z~:~=i ~
z i-~~;; ;i ia the ta~ces enu- _,~it~W~ /l
t ~erated belaw, toge~her with all stotu~vry odddions provided by Section 6321; ond u~+?R~ /J
tho? ihe lien For :ucl, tw~s cnd srosutor,? «idit'eorn fias ihcreb,? been releasea. n~e ~ f~~'1~
proper oA'ionr in the ofi'ioe wfiere no1Ke of inlmmal ~arenue tax I+en wos filed on
, 19~_, a hereby avM~orized to make notation ~
on h,s ro' the releosa of said I~en, insofar as ths lien relctes ro the fdlo~w- , •
in~ Mxes. ,
ru~ oF rAxg+?Yet 35Q483
O~Ml~a L ~iiitia~
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• tNVPA1D BJILANCE
KIND OF TAX TAX PEWOD ENDED ASSESSMENT DATE IDENTIf1fING NUM68t OF /1SSESSMENT
(a~ (b~ {c~ Idl (el
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PLACE OF FlLIIVCa
, . ~ TOTiu ; 1 ~ 530.8~i
~ Fvrt Pbro~. F1ork~s
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Jacksonville, Florida
IARtN~SS nry ?~d cit , on this,
29th October 76
t}1e cby of , 19
60t3~ ~ }'~GE ~
S~GPIATURE ~
c Durant Chief, Special Procedures Staff
(NOTE: CertiR of oRicer wlFarized br law to take aclutiawledpments is not essemid ro Mie ralidihr o# Nwia of f~d~rd Taoc lisn G.C.M
2b419, C.B. 1 Sl, 1~5.)
as
PART 3--To b~ us~d tor nco~na pw~pos~s ~
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