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STATE OF FLORIDA
l,~S FORM UCT 18 DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
~REy, ~t~ DIVISION OF UNEMPLOYMEIIlT COMPENSATION
BUREAU OF TAX
TALLAHASSEE, FIORIDA 32301 ~Q~~
~ TE L. 804/488-7621
NOTICE OF TAX LiE1V P2~7 .
~ Employer. FiLED L.h .
O e TRlKKZNf'i ~ t,SOMS INC Acc~~:nt Number 6i`~ZROGER ~Ji; i~,:.;. %~K
~931 AMECI STASET SL IUCIE COLH i Y. FL.
PQIZ~ :ti? t.Y4EE Fi. ~3+65 Lien IVumber 5~161~7
IV?JG~~Q
Pursuant to the provisions of Section 443.141(3) (a! and (g} Fiurida Statute;, known as the lien provisions of the ~lorida Unem- ~
ployment Compensat~on Law, notice is hereby given that the above named employer is liable for the payment of contributions to the
Unemployment Compensation ~und of Florida. Pursuant to the provisions of said law, the folfowing contributions, interest, penaliies,
and fees which after demand for payment thereof remain unpaid, and that by virtue of the above mentioned law, the~amount of said
contributions (taxesi together with interest, penalties, and other costs that may accrue in additiorr thereto, cor?stitute a lien in favor
of STA7E OF FLORIDA DEPARTMENT OF LABOR AND EMP~OYMENT SECURITY upon tne title to and i~te~est, whether lega!
or eyuitable, in any real property, chattels real, or personal proper[y of said employer.
Perials for which contribut~ons, interest, penalties, and fees have been assessed, and the amounts thereof, are as follows:
i Q/VR TAX DUE INTEREST THROUGH PENAITY SERVICE FILING
' oa~?o~;aa DUE FEE FEE
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~ ~ /8i • iZ6.36 • 1.40 - is.00
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~ TOTAL AMOUNT OF TAX LlEN • la3•2b
V111TNESS THE OFFICIAL SEAL OF THE STATE OF FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT
aFCURITY, ~VISION OF UNEMPLOYMENT COMPENSATION, at Tallahassee, Florida, this 6TN
day of Y , A. D. 19 ~S
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~ ~ ` AGENCY USE OHLY
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- REMIT NO. fyATE 5
• AMT. S NO PAY.
BQIIK ~1J~ PaGE t~1 i. ry~ P•M• DATE FILED ~
IK ti: s ~ Davis
REPORTS F.A.
This instrument prepared by: ~ ~ .F.A. NO.
SMZAL~Y ~.E(~IARD F.O. NO. s~A ~ l. ONLY O. INDEBT.x
Departrnent of Labor and Employment Securiry
Caldwell Btdg., Tallahassee. Fla.
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