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Olplrlmal1t 01 Ihl Tra..ury , Il1t.mol Rov,nua eurvl~1
Form oeo (VI (01
'Iflov Oclullul 100:!)
I
Natlce of federal Tax Lien
Ololrlct ~;.. , I " lSOlllll NUIlII;.~,___._,__
A. provided by IOcllono 6321, 6322, and 6323 01 Iho Intofllul Rovonuo
Cod., We Ire giving a nollc. that to)(OO (Including Intorost ol1d ponolllos)
hive been ou.ued agolnst the following-named to><poyer, Wo hove mod.
. d.mand for plymenl of thll lIablllly, but II romolno unpDld, Thore'ore,
thoro II . lien In flvor of the Unlled Statns on all property ond rlghto to
, property belonging 10 Ihl. ID><poyer for the Dmount of Ihlloe 10><00, Dnd
i .ddlllonel panllll", Intoreol, ond cosio thot rnoy oeCrUO.
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NDme 01 TD><poyor I. , ,I"
Reoldol1ce
, 'I', II III
'1.1 III I
IMPORTANT RELEASE INFOI1MATlON For each o~~e~~lIwl1l "~Ied IJelaw,
unless nollce 01 1101110 rallied by Iho delle glvel1l!1 calullIl1 (0). 1I11~ 110l,co ~11Ul/,
on Ihe dey lal/owll1g such dole, opottllo a~ a cOlhlir.ale 01 !Urease O~ delllled
In IRC 6325(a .
To)( Period
Ended
(b)
Kind of Ta)(
(s)
001001
Aooossf11onl
(d)
Lost Day lor
Rollllng
(tJ)
Idenllfyll1g Numbor
(e)
I ,. , I " i' " , ,
I , ., , , , "1 ., ,I.' ,./1 "
, i' , ! I.. I .:i. I I. " , 'I.
Ploce 01 FIling
I ), ,J ,I" 1111',," '~
I, 111,11 ,.",' lIt" 'IJIIHt Y
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Thlo nollce was prepared and signed Dt ,'I' I ,," .", , ,'\
the " , ,I day of
)1 I','
,19~.
1'1
Slgna7' It. / ,;.
~ . f .
. . r. I I" l' 1 ~ . "I ~'J,; 1 1'1
,f. ~..
Tille
f\L.. ( llu
1jlj"','\111
(~II II ,:r.t. ")
q ',).L\. ~ fll
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,1'1
!
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q Iq~)c..
Unp.'d Bllone.
of Au.um.nt
(I)
r\ ,1
I. II
I I It
I I.
Total $
(,'Ill 'i. JI
, I .1, I , t, I ~
I , .; 11\ I. " f.'
I '1,1 (0,. I d
, on this,
(II l-lll
,1'01 I II! 10 r,
PDrl 1 . Kept By Rceordlng Offlec
(NOTE: CertlfleDI. 01 olflcl' lulhorlud bV law 10 Illk. uckl,owllltJgmlnlU I, l\olUSQnllul 10 Ih, vDlIlJlIy 01 Nollel Dr Fla,r.1 Tile lI,n
AlV. Au!, 7HCC, 1071 ,2 co. ~091
Form 660 (V) (c) (Rev. 10/93)
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