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Form Q~~ D•ptartmMt of tM Trwury • Int•rnY R~v~raa• S~rvfc~
(Rw. sovt.mt».11i7a) Certificate of Release of Federal Tax Lien
District S6rial Number Fo. ovtlorw ta• M A•co~drnp care.
Jacksonville Not Shown ~ •33 ~I~~1 T f~ ~Y' , ~
il.: f' ARE (•e , ~ D
1 certify that as to the following-named taxpayer. the requirements Of section 6325(a) Si' ~ !ti+:1F ce ~ r. t t A.
of the Internal Revenue Code have been satisfied for the taxes listed -below and ~ s
for all statutory additions. Therefore. the Ilan provided by Code section 6321 for ~t~``'' c"`~~'; 1;GURi f~
1tFrd~F Yi 91f U_ . ~ 7
these taxes and additions has been released. The proper officer in the office ~ .
where the notice of internal revenue tax lien was filed on May 23, ,
18 78 . is suthorixed to note the books to show the release of this lien for ~C~3
these taxes and additions. aA...i
Narrt~ofgTaxpay~r Horn, Sr. -
u ene
Donut Fair
Residence
1109 N. Federal Hwy. -
Fort Pierce, F1. 33450 '
Unpaid Balance
Kind of Tax Tax Period Ended Data of Assessment Idsntifyirp Number of Assessment
UJ [b) !cl rd) (~1
i
~ 941 12/31/77 03/27/78 59-1603301 6297.04
i
i
1
Place of Filing Clerk of Circuit Court . _ -
St. Lucie County Courthouse Total = 297.04
~ Fort Pierce, F1. 33450
s
Jacksonville, Florida
This certificate was prepared and signed at . on this.
r
the 8*_h Octobe 1g 80
Signature Title
~ Van E. O'Neal ~ Chief, S ecial Procedures Staff
twa~ c«rmc.r• a onre•r ..wnorr:•d br ?.r ro nk. aaknowadp.rnq 1S w ro u+• vxari? a Nare• a
f F•oerar fax Lhn Q.C.M. 264fO, 111301, C.B. 12bJ 8~~~r~i~r r~
Part 3 - To be used for recording purposes Fwm 868 (Rev. 978)