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Form ~ D~ptattttNnt d tM TrNwry - IMKmI Rrwnw SNVIo~
(R.,r.$pt.mb.r,o7a, Cede of Release of Federal Tax Lien
Oisttict Sorid Number Fw optlottd ua br A~cotdrq onro.
1a1lllae iR.
I oertiiy that as to the fdiowing-named taxpayer, tl~e requirements of section 8325(a)
of the Intefr,ed Revenue Coder have been satisfied for the taxes listed below and
for 811 statutory additions. Therefore, the lien provided by Code section 8321 for
these taxes and additions has been released. Tate proper ffio~ in th office
notice of intemai revenue tax lien~was filed on
19 . is authorized to note the bodcs~to show the rel a of thi lien for `
these taxes and additions. O ~ 30(0 _ ~ l ~9
Nantp of Taxpayer
i
Residence
~ ~r~ l.~ll~t
1t. Mll3~is S3~
unpaid iBslartce
Kind of Tax Tsx 1'erbd Ended Date of Assessment Idsndtyttq Number of Assessment
(a) (D) (c) (dl (~I
1
100 l~l~~ l0*02-7ij 311~It>t~~~0 t 1e181.03
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Place of Filing Clea'k ~ ~ ~t
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v Hetr~ Flarid~ 0 Totsl i 1,111.Q3
Tttf~certificate was- , on this,
the day of,~~~ ,19 _ t
Signature Title
Mott; CNtificata or oHkar uthorizsd by (aw to taM acknowkPdQmanta not ess.ntial to tM validtfy of Nock. of
Federal Tax Uan O.C.M. 261 , 1DS0~1, C.B. 12b.)
PaA 3 - To be used for rot~ordinp purpoees Form 668 (Rev. 5.78)
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