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Department 01 Ihe Tre8lury. Inlernal Revenue Sorvlc.
.orm 868 (V) (c)
(Rev. October 1993)
Dlstrlcl
Notice of Federal Tax Lien
Serial Number
For Opl/onel U.. by Recording Ollie.
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" At provided by aectlons 8321, 8322, and 6323 01 tho Internal Rovenue
I, Code, we are gIving a notice thettaxes (Including Interest ond penalties)
Iti have been allesaed agelnst the followlng.nemed taxpayer, We have made
. demand for payment of thlt lIablllly, but II remains unpaid, Therelore,
there Ie a lien In favor of the Unlled Stales on all property and rights to
property belonging to this taxpayer lor the amount olthess taxos, and
~ additional penalties, Interest, and costs that may accrue,
/jNameOfTaxpayer [OI'jAnll .J :J ,1'.',([' "'1,::1:1'111""'.'" 1
I Residence
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:1818 rOF'f"EFi I:ETIL[ Iii>
rAl~p HILL, "A 110)11
IMPORTANT RELEASE INFORMATION: For each assessment listed below,
unless noUce of lien Is reflled by the date given In column (e), this nollce shall,
on the day follOWing such date, operate as a certificate of release as defined
In IR 2 "~'C-"r'o '"'''H''''''^' ''''11'- '"' (," ,,"...
Tax Period Date 01
Ended Identifying Number Assessment
(b) (e) (d)
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KInd ofTax
(B)
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Last Day for Unpaid Balance
Reflllng of Assessment
(e) (f)
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Place of Filing
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Total
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This nollce was prepared and signed at
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. on thle,
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t 7 t:" day of 11 a I .. h
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Signature
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Tille
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(N6T~i liiMitll' .sf ciriiC;, .~thoIIZOd by Ilw 10 Ilk I l,knowlsdgmsn'. I. nol I..snllsll. tho volldlly 0' N.Uel ., Fldl'll TIX IIln
Rlv. Rul, 71,.00,1071. 2-0,8, ~09)
Port 1 . KepI By Recording Otflca
Form 888 IV) (0) (Rev. 10/93)
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