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Oeportment of Ihe Treo9ury . Internol Revenue Service
Notice of Federal Tax Lien
Istrlct
Serial Number
1\1,-,
As provided by sections 6321, 6322, and 6323 01 the Internal Revenue
Code, we are giving e notice that taxes (Including Interest and penalties)
! have been assessed against the following-named lax payer, We have made
1 a demand lor payment 01 this liability, but It remains unpaid, Therelore,
I thsre Is a lien In lavor 01 tha United States on ell property and rights to
I property balonglng to this taxpayar lor tha amount of these taxes, and
, additional penalties, Interest, and cosls that may accrue,
,
jName of Taxpayer
i
IMPORTANT RELEASE INFORMATION: For each assessment listed below,
unless notice of lien is refiled by the date given in column (e), this notice shall,
on the day following suell date, operate as a eertilieate of release as defined
in IRC 6325(a),
Tax Period
Ended
(b)
i
IResldence
Kind 01 Tax
(a)
Identllylng Number
IC)
Date 01
Assessment
(d)
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1
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;Place of Filing
This notice was prepared and Signed at
the
day of
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For Optional Usa by Rocordmg QI/lce
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Last Day lor Unpaid Balance
Rellllng 01 Assassment
(e) (f)
Total $
, on this,
(NOTE: CUll,lH',lt" n! <,tl'e.'1 ,Hd!)i!tl~f!\j 11'1 i,IW II) la,'I' ,ld.'-o,...IlHJlj;JHn1I~, I:; n'~,II!';:;.!n!ldl1o lhtl validltv 01 Nolleo or Foderal Til:.l: Ii un
flov nul 71 .,,;1";. Uti ~ C b .\wll
Part 1 - Kept By Recording Olllee
Form 668 (V) (Rev, 10.93)
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