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Form 668 (V) (c)
(Rev.Octobor 19!131
OI}IHI~I"ll.'llt olll1u 'TtOllIHlfY . Inlu/'lHll nuvonuu 50,v1CG
Notice of Federal Tax Lien
District
SUflal NUflllll!f
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A. provided by .ectlons 6321, 6322, ond 6323 01 11\0 Internal HovQnllo
Code, we are giving 0 nollco thottoxos (Incllldlng Intorcst and ponolllcs)
have been assessed ogoll1st tho followlng.nol11ed lnxpayer. Wc tlave l11ado
I demand for payment of this Iloblllty, bllt It rel11ulns lI11puld. Tl\oroforo,
there Is a lien In favor of the Unltod Stato~ 011 all proporty and rights 10
property belonging to this taxpoyer far tho amollnt of thoso taxc" ol1d
Iddltlonel penalties, Interest, and costs that may accrllc.
Name of Taxpayer
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Residence
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IMPORTANT RELEASE INFORMATION: For ench "~sessl11enlllsltFj below,
unless notice of lien Is reWed by the dale given 111 cclul11l1 (~I. Ihl5 110\lce shall.
on the day following such date, operate us a certlllcalo of rel~nse os delll1ed
In IRC 6325(a).
Tax Period
Ended
(b)
nq.<"(J~~
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Kind of Tax
(a)
Idenllfylng NlImber
Ie)
Dote of
Assessment
Id)
e."
Last Day for
Rollllng
(e)
'i'; :1'b'4.>
Unpaid BalanCI
of Asseum.nt
(f)
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. Place of FIling
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Total $
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This notice was prepared and signed at
, on this,
the
day of
, .
,19_..
Signature
/)1 Tille
L);drr;J......IJ."~a)'"- ' "
(NOTI: Certlflcate 0' clllc.r authorized by law to !ilkl acknowledgmlnt' II not nsenUallo th. valldltv 01 Notice 0' ~.der.l T.. IIln
Rlv. Rul. 71.466,1871.2 C.B. 409)
Pllrt 1 . Kept By Recording Office
Form 668 (V) (c) (Rev. 10/93)
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