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STATE OF FLORIDA GJ~
;,r" ~ DEPARTMENT OF ~ABOR AND EMPLOYMENT SECURiTY
_ , DIVISION OF UNEMPLOYMENT COMPENSATtON
~ BUREAU OF TAX
TALLAHASSEE, FLORIDA 32301
TE L. 904/488-7621
~~3Q853
fVOTiCE OF TAX LIEI~!
_.,.:;;luyer~
L E<U Y S ELi_A M Y Account Number 7 L:~_ ~
2114 N 43FcU ST
F T PItRt.t FL. 33450 Lien Number ~-~~.~.~q
?urs.~ant to the provis~ons of Sect~on 443.141(3? (a? and (y) Flarida Statutes, known as the lien provisions of the F;orida Unem-
~~loyment Compensation Lav~, natice is hereby given that the above named employer is liable for the payment of contributions to the
Un~n~ployment Compen,ation Funcl af Florida. Pursuant io the provis+ons ~f sa~d (aw, the following contributions, interest, penalties,
and fe2s r:hich after demand for payment thereaf remain unpaid, and that by virtue of the above mentioned ta4v, the amount of sa;d
contributions (taxesj together with int~.est, penaities, and other costs that may accrue in addition thereto, constitute a lien in favor
:;f STATE OF FLORIDA DEPARTA9ENT OF LABOR AND EMPLOYMENT SECURI~Y upon the title to and interest, v~hether legal ~
or equitabte. in any rea{ property, chatieis reai, or p•rrsonal property of said employer. ~
~ Perials for which contributions, im.~r~~st, {~en~ltie;, and fees have t~een assessed, and the amounts thereof, are as fal~ows: '
4
~Q/YR j TAX UUE , INTEREST THROUGH PENALTY SERVICE FIUNG
' i ~UE FEE FEE
; 11/i; 1/da
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: _ ~idw a~ ~c~.E~ ic.~c , i~.~;.
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~ :
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! '84 t~OM1I 1b Rtt :10 ; ~ ~
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~ ~ FIL~`'' ' ~
€ ; ROGE~~ ~ ~ '
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~ , ST. LUCI: _ ~ . ! ~
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~ ----1-
~ TOTAL AI410UP~T OF 7AX UEN j- 1~~-
£ `,"11TNESS THE OFFICIAL SEAL OF THE STATE OF FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT
~ CURITY, DIVISION OF UNEMPLOYMENT COMPENSATION, at Tallahassee, Florida, this i~~
: , ~f ncv~a;~:~~ , A.D. 19 a4
4~~,,, ~
` ~ AGENCY USE ONLY
~
~ ~F 3 t
~ ~ ~ REh11T NO. DATE 11/14/8~4
S. ' 9 d~Q ~ T - AMT. 5 NO PAY.
~ -''._1 ~3V P..l~ Q z
~ - _ y~ plyl DATEFILED 11~14~8~
~ y ~ REPORTS F.A. Davis
~ This instrument prepared by: ~ ~ ~
~
St1ltiLcY Lc~lNAt10 F.O. NO. ~-t~ L.ONLY O. INOEBT.~
~ Department of Labor and Employment Secur~ty
f
- ~~ald:vell Bldg., Tallahassee, Fla.
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