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t?or~ 66{-F DEPARTMENT OF THE T~t[AlURY • INTERNAL pR1R~NUt t1ERVI~ ~ Fa. Op,aMl Ut• Br.R~cw1+p OH.c•
t:•n~ CERTIFICATE OF ASE OF FEOERAI T X LAN -k3
DIfTRK7 ~ tt~ 1~1
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~ 1 hor~by eortify that os to tM followtny-iN~i~d txyoyr th• roquir•monti of Section»
" 6345(oi,~, lntornal Rovonw Codo, Novo bo~l~tis(i•d with rospoct to tho toxolionu- 7
worotot} below, topothor with all srotutorl/'i~ditiyens provided by S•etion; 632~j and , i~19 ~n~ "2 All i~ ~S
tlset tlss> lion for such roxos and srotutory additions has tMroby bo*n rol*oso~. "TM' -
prQp~r~ e~f1~o? in tla offiu whoa notice ~i
intomo) i•vonw rox lion w•s fibd on E A j~~ f~~fD
i y' r^ 19 is Mroby euthai:od to nako notation ~ ~ R P~~I1fRASA.
*n his•.books to stow tM rolwso of said lien, insofar as tM lisin rokros tFb the ~ T
felfewirl0 toxos. ~ ~ r
t NAB ~~PA~E~ RE~OItD VERIF
J >s o01~ rle~c~ .~r, r, - 44?.bifil
RESIDENCE
1~M ~ " :3 r
- UNPAID BALANCE
KIND OF TAX TAX PERIOD ENDED GATE OF ASSESSMENT IDENTIFYING NUMBER OF ASSESSMENT
!a) Ibl I~l ldl (e
941 12.31-67 Q=-2L72 59•LD2879S s; 889.13
941 09.30-67 Ot•21^72 59-1028795--" - 990.22
• "
r PLACE OF FILING (;1!><k OE LIM C~Z~t COIi1>rC
E ~ ~Ol~dt TOTAL : 1879.95
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NOTICE OF FEDERAL TAX LIEN REfIlIN6
30~}77_,
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F P IRS SERIAI NUMBER RECORDER'S IDENTIFICATION NO._____-__-______
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~ NOTICE FILED WITFICII='te Clt'Cil?iL COatL, St. LnCi! COIiIILji Ffc• DATE G 'n ~7
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{ TAXPAYER'S ADDRESS '
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( ~ erlnt than shown above) - - - -
SIGNATURE ~ A• ? ~-G„' TITIE ~_1rAi1~! - - - -
I ,
1 WITNESS my hand of ~ ' , on this,
the day of _B,P 9-a J
SIGNATURE _ Van-~_ SZ ` l~~ TITIE-_ ~''_e' . Spec ~a! Pr~~cec~ gyres S~ a
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' (NOTE: Certificate of officer authorized by law to take ockrwwledgments is'not essential to the validity of Notice of Federal Tax lien
G.C.M. 26419, C.B. 1950-1, 125.)
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PART 3-To be used for recording purposes
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