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STATE OF FLORlDA
~ES~ORM UCT 18 ~EPARTME!~!T OF LABOR AND EMPLOYMENT SECURITY
~REV. ~t) DIVISION OF UNEMPLOYMENT COMPENSATION
BUREAlJ OF TAX r~ ry
TALLAHASSEE. FLORIDA 32301 IOl~O
TE L. 904/488-7621
NOTICE OF TAX LIEN ~D P2~~
m~loyer. FILEG t.: :t J
GER PUI ~ r:A ~ ;::.c KK
- NORR2S' EOiE NASONAY' IMC Account Number ~s~p LUCIE CO;;!~''Y. FL.
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- ii60' GAILMONT. LA~tE ~
PaRT ~T- LYCIE IR 33~52 Lien Number 5-~~~a6
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Pursuant to the provisions of Section 443.141(3) (a) and (y) Florida Statutes, known as the lien provisions of the Florida Unem-
ployment Compensation Law, notice is hereby g+ven that fhe above named emptoyer is liable for the payment of contributions to the
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Unemployment Compensation Fund of Florida. Pursuant to the provisions of said taw, the following contributions, interest, penalties,
and fees which after demand for payment thereof remain unpaid, and that by virtue of the above mentioned law, the amount of said
contributions ltaxes) together with interest, penalties, and other cvsts that may accrue in addition thereto, constitute a lien in favor f
ef STATE OF ~LORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY upon the titte to and interest, whether legal
or equitabie, in any real property, chattels real, or personal property of said employer.
Periais for which contributions, interest, penalties, and fees have been assessed, and the amounts thereof, are as follows:
~ QlYR TAX DUE INTEREST THROUGH PENALTY SERVICE PILtNG
i _ v~Oj'~ OUE FEE FEE
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~l84. 289•'Si f?•34 • 13.00
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Q TOTAL AMOUNT OF TAX UEN a0,~+~ I
~ ~VITNESS THE OFFICIAL SEAL OF THE STATE OF FLORIDA DEPARTMENT OF LABOR AND 6TH~~YMENT
`~ECURITY, [~IA~SION OF UNEMPLOY~M~ENT COMPENSATION, at Tallahasses, Florida, this
~_iav oi , A.D. 19
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' AGENCY USE ONLY
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- REM1T NO. DATE S~2I1~5
~Q~ - AMT. S NO PAY.
B(JOK~~~ PAGE '~/VV ~ t~` ~ P.M. DATE FILED r3 Zl ~j
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REPORTS F.~. Davis
Th~s instrument prepared by: ~ ,F.A. NO. OQ101
SMLRLEY.•~~OaIARO F.O. NO: ~ L. ONIY O. INOEBY.x
Department of Labor arid Etnptoyment Security -
Caldwell Bldg., Tailahassee, Fla.
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