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STATE OF FLORIDA
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F~,~;A, DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
7~ DIVISION OF UNEMPLOYMENT COMPENSATION
BUREAU OF TAX
TALLAHASSEE, FLORIDA 32301
TE L. 904/488•7621
6~3'~863
NOTIC~ OF TAX LIEN
~ ,,i;,loyer.
~ N f: iCHAF.O S(:His'P Account Number .
tv i•IChAriU SCH(;PN' Lt1i~Y~Fi
SU1TE 2C4 Lien Number 4_~y~~ ,l
b410 S~.UTh FEG~:~tA~ H16f:eiAY
Pt;.l:T ST LUCIE FL ::.452
Purs~~ant to the prov~sions of Section 443_141{3) (a) and (y) Florida Statutes, known as the lien provisions of the Ftorida Unem-
;~loyment Compensation La~v, notice is hereby given that the above named employer :s liable for the payment of contributions to the
Unemployment Compensation Fund of Florida. Pursuant to the provisions of said law, the following contributions, interest, penalties,
anci fees rvhich after demand for payment thereof remain unpaid, and that by virt:ie of the above mentioned law, the amount of saicl
contributions {taxesj together with intPrest, penaities, and other costs that may accrue in addition thereto, constitute a lien in favor
of STATE OF FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY upon the tit!e t~ and interest, whether legal
~r eyuitable, in any real property, chatte0s feal, or personaf property of said employer.
Periais for ~vhich contributfons, ir*.er~st, peralties, and fees have been assessed, and the amounts thereof, are as follows:
Q)YR TAX DUE i INTEREST TFIROUGH PENALTY SERVICE FILING ~
4 ~UE FEE FEE
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- '~'/d4 A i 1 C;:.3C ; 1. ~8 1;.>. iiG
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TOTAL Ah10UNT OF TAX LIEN 1 c 2. c:
` y:~ITNESS THE OFFtCIAL SEAL OF THE STATE OF FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT
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>~CURITY, DIVtSION OF UNEMPLOYMENT COMPENSATION, at Tallahassee, Florida, this 1~~
; ; ~y of ~ov=~ttr~ , A.D. 19 ~a .
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~ ~ AGENCY USE ONLY
~ v'~J~K t'~ jr ~ ~ ~ REMIT N~. DATE 1.1~ 1.
~ ~ ~ ~ - ~ AMT. $ NO PAY.
~ `2~ '~~A~,~'~' ~ P.M. DATE FtLED _ 11~14~ ZI
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~ ~ REPORTS F.A. DaV1S
This insL•ument prepared by: ~ ~
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~ SHI N~~Y LE_uNAfiG F.O. NO. ~-~A l. ONIY O. INDEBT.
¢ DeRartment of Labor and Employment Security ~ -
~ Caldrvell Bldg., Tallahassee, Fla.
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