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F~ pepartment ot the Treasury - Inter~al Revenue Service
(Rev.September19781 Notice of Federal Tax Lien Under Internal Revenue Laws
~IStfICt Serial Number For Optional Use by Ftecwd~ny Office
Jacksonvill~~ r~i. ~79 KAY '3 ~ ~ 45
As provided by sections 6321. 6322, and 6323 of the internat Revenue Code, F0.E0 ~ C~D
notice is given that taxes (including interest and penalties) have been assessed =
ROg ~~IT ~ A
a g a i n s
t t h e f o l l o w i n g- n a m e
d t a x p a
y
e r. D e m a n d f o r p a
y m e n t o f t h i s li abili ry has a, q
t K H t
been made, but it remains unpaid. Therefore, there is a lien in favor of the United R~coaO vFaiF~EO. ~
States on all property and rights to property betonging to this taxpayer for the
amount of these taxes, and additional penatties, interest, and costs that may 44 ~~24
accrue.
Name of Taxpayer
.:c3T'~/ vT• ~I.Bfli,tll ~
Residence ~1~ ~{,jl S}.,reet ~
"r't. i erce~ :'l. 3~45~
Unpaid Balance
Kind of Tax Tax Period Ended Date of Assessment Identifying Number of Assessment
~ (a) (6I lc) (d) [e)
~ 1040 1;>_-31-75 0~.-~,~-79 251-55--w7ob '7~2.10
~ 1~1:0 12-31-7b o3-2r-~-79 :~~1-~6-1T?65 ~3k•77
~ ~0~ 12-31-77 ~4-~~2-?9 261-5 ~-1;76G 337.~8
` 1~J1~p 1?-:1-78 os-1~-79 2b1-5~
_1~ry;; ; ~2.J0
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~ Place of Filing
. ;lerk o; Circuit CoLrt
~t. Iucie Co~:c:ty Co}a.rtY:ouse Totat = 1~~»•95
~ :`t. :'~~rcc~ :lori:ia 3~1~70
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~ This notice was prepared and signed at Fort °ierce, -Flo-ri .:a , on this,
~ the l:,t dayof ~••~:~;I ,ts 79
~ .
~ Signature Title L' ~S ~ O
- E~:,! ~AC~ Y.l.
- for . ~~~vn:~::e Oi~icer -
~ .
(N : Certifica~e of orrwer utAorized Dy law to take ~cknowledpments is not assenti~l to the valitJify ol Notice o/
Feders! Tax Lien G.C.M. 2d~1 , 195f}1, C.B. 125.)
~ Part 1- To be kspt by recordiny oftice ~ Form 668 (Rev. 5-78)
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