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ST/~TE OF FLORIDA ,
/
DEPARTMENT OF LABOR FMPLOYMENT SECURITY
. , r.:.
~ ~ DIVISION OF UnitnnrLOYMENT COMPENSATION
BUREAU OF TAX
TALLAHASSEE, FLORIDA 32301
TE L. 904J4$8-7621
~'~~~6 NOTiCE OF TAX LIEN
_
~ UPIVEh~AL MICA ING AccountNumber ~q~l::i
1 E1N ~E YILLACit GkcEh DR 7
f~(shT ST LULI E f-L .:.345t Lien Number 4-;::,~ ~C
Pursuant to the provisions of Section 443.141(3) (a? a~~~ ;y) Florida Statutes, known as the lien provis~ons of the Florida Unem-
;,;oyment Compensauon Law, notice is hereby given that the above named employer is iiable for the payment of contributions to the
Unemployment Compensation Fund of Flonda. Pursuant to the provisions of said iaw, the following contribuLions, interest, penalLies,
;nd fees which after ~emand for payment thereof remain unpaid, and that by virtue of the above mentioned law, the amount of said
~~~ntributions (taxesj togeiher with ~n?Prest, penoit~es, and other costs that may accrue in addition thereto, constitute a I~en in favor
;f S?ATt OF FLORIDA DEPARTAIENT OF LABOR AND EA4?LOYMENT SECUFsITY upon the title to and interest, whether legal
,r e:auitable, in any rea~ property, chattels :eal, o: ~ersonal pr~perty of said employer.
Pznais for ~vh~ch contributions, intarest, pencities, and fees have been assessed, and the amounts thereof, are as follows:
Q/Y~ TAX DUE -r INTEREST THROUGH PENAITY SERVICE FILING !
I 11/O l/t~4 DUE FEE FEE
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i -
f... ~ia4 n; i,3~~.aa 2o.2s :5.c::
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~ ; ~ ~ '84 t~Y 16 ~q1 :11
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I I FIL~['
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c ; , ; ROGEF _ ; h
~ ; ; ; ST.IU~~~ , ' '
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I I ~ I 6$~8~i~
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TOTAL AMOUNT OF TAX LIEN 1• ~ ~
~ `,`:I~TNESS THE OFFICIAL SEAL OF THE STATE OF FLORIOA DEPARTMENT OF LABOR AND EMPLOYMENT
, E CURfTY, DIVISION OF UNEMPLOYMENT COMPENSATION, at Tallahassee, Florida, this
; t~LY EM E.Ek c~a
' ; ~ of , A.D. 19
~ ~a°°r
~ T~ ~ AGENCY USE ONLY
~ ~ ~ REMIT NO. DATE 1-1 1
~ ~ ~ - ~ - ~ AMT. S PJO PAY.
-.'_'_~'~4~ Q~~~ ~'c 5~~~~~ ,7 P.M. DATE FILED 11/1 ~ ~
~ `y REPORTS F.A. D3V1S
Th~~ insirument prepared by: ~ ~
t
~ SHI RLtY LcUNAFiG F.o. r~o. ~-LA L ONLY O INDEBT."
~ Cepartment of Labor and Employment Secunty
~ Caldwell Bldg., Tallahassee, Fla.
~
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