HomeMy WebLinkAbout1310 1 YOU MAY SEPARATE FORM AT PERFORATION At>10VE FOR OORRECTIONB
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Form 668 Department of the Treasury • Internal Revenue Service
(Rev.september1978) Notice of Federal Tax Lien Under Internal Revenue Laws
District Serial Number perry Fa Oprionaf Uss by,RYecadap Office
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As provided by sections 6321. 6322. and 6323 of the Internal Revenue Code. STRL ~
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notice is given that taxes (including interest and penalties) have been assessed 1~0~6ER p~~~
against the following-named taxpayer. Demand for payment of this liability has CtE1111 CIRC1?It COtBt
been made, but it remains unpaid. Therefore, there is a lien in favor of the United RECORD ~'ER~IEO
States on all property and rights to property belonging to this taxpayer for the -
amount of these taxes, and additional penalties. interest. and costs that may 4~'7a3a3
accrue. .
Name of Taxpayer ~ -
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Residence
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Unpaid Balance
Kind of Tax Tax Period Ended Date of Asseasantent Identifying Number of AssisssmeM
(a) (b) (c) (d) (e)
1040 12-31-78 06-16-80 123-34-1r8GG v 364.88
1040 12-31-7y Ob-02-80 „ „ Y 1,368.08
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Place of Filing a~ ~e
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~T .UC_ CLI::iY ~LL`:Cl' :.u~L TOtel = 1,732.9E
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This notice was prepared and signed at PI~c:: • i'Z~ , on this,
the ~ t;h day of :
•.B':;: ST .19 80
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Sign ure Title
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(N Certi/irate of o ar surhwrzed by few to fake acknowledpmsnta b not essenfla/ to ffa va4dlfy of Notice o/
' Fade Tax Lfen O.C BatD, fO50.1, C.B. 125.) g a[l~~~ Pln[~~
Part 1 - To be kept by recording C~Itd~~`~ II~uCC Form 668 (Rev. 5.78)
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