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STATE OF FLORIDA tr~
DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY ~
.1; DIVISION OF IJNEMPLOYMENT COMPENSATION I
BUREAU OF TAX ,
TAILAHASSEE, FLORIDA 32301 I
TE L. 904/488-7621
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NOT!~E OF TAX LIEN
~ _ • ;~!u,er:
G~kl_ L l~CKI NNE.Y Account Number ~
GI:STOH FAw~1GATiN~ E W~i..Dtrv~
1 i U`1 AN(i1.E RO /?J Lien Number y_ 7~ i
F T PI~:~Cc t=L .;345C
Pun~a~t to the provisions of Section 443.141 {3) fa) ar~d (y) Florida Statutes, known as the lien provisions of the Florida Unem-
;~loyment Compensation Law, notia~ is hereby g~ven that the above named employer is liable for the payment of contributions to the
lJnemployn~ent Compensation Fund of Florida. Pursuant to the provisions of said law, the following contributions, interest, penal:ies,
an~.f fees :~liich afte.r demand for payment thereof remain unpaid, and ?hai by virtue of the above mentioned law, the amount of said
COflt~~butions (taxes} together ~vith ~ntPrest, penaities, and other costs that may accrue in addition thereto, constitute a lien i~i favor
of STATE Or FLORIDA DEPARTMENT OF LABOR AfVD EMPLOYMENT SECURITY upon the title to and interest, whether legal
or equitable, in any real property, chattels real, or persona! property of said employer.
E Periafs for which contributions, +nterest, p~~nalties, and fees have t~een assessed, and the amounts thereof, are as follows:
~
j Q/YR TAX OUE ~ INTEREST THROUGH PENALTY SERVICE FILING i
; ~ ~ ~UE ~ FEE FEE
; ' ! ~ 11/O1/c34
~
E.. K/ti4 A ~ 5. T7 ~ . Gy 1 G.
i j t
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~ ~ j '84 I~V 6 A11 ~ !
~ ~ ~ ~ .
~ ~ F~~~c : I
~ I I ~ ROGER r , •'r,
~ ~ ' ST. LU~~z c. r_. I
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a ~ i ~
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~ ` I ~ 6~~~6
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TOTAL AINOUNT OF TAX LIEN <<:. ~L
':"dITI~ESS THE OFFICIAL SEAL OF THE STATE OF FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT
`:`CURITY, DIVISION OF UNEMPLOYMENT COMPENSATION, at Tallahassee, Florida, this 1:: +
` +.ay of nuv~~bE~ , A.D. 19 .
~ Lat~ a~~
:
; ' AGENCY USE ONLY
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~ - c* REMIT NO. DAT~ 1/ 1
~ ~
~ ~,R u ~ - AMT. S NO PAY.
~ ~ •!';K P!.Gf ~ ' ~
~ ~ ' ' ; ^ P.M. GA i E FILED 11/14/ ~
~ S F REPORTS F.A. D2.V~S
• •
Th~s instrurrwnt prepared hy• ~
~ _ bNl~ii_EY l.~l~N/~i~t~ F.O. NO. t-~A 1_.ONLY !t O. INDEBT.
x Department of Labor and Employmen* Security
g Caldwell Bldg., Tallahassee, Fla.
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