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DeJlertment of the Treesury - Internel Revenue Service
Certificate of Release of Federal Tax Lien
District
PENNSYlNANIA
Sorlol Numbor
For Usa b Recoruln Offlco
239736122
I certify that as to the followino.name tBxpoyer, tho rOQulru"1onts or suction 6325 (u)
of Ihe Internel Revenuo Code havo be.n satl.flou for tho tox.. II.tou bolow anu for
ell .t.tutory eddltlon., Therefore. th. lien provldad by Code ..ctlon 0321 for tho.e
t..e. .nd eddltlon. he. boon reloe.ed, Tha prop.r officer In tha office whoro tho
notice of Internal rovonue t.. lien we. filed on December 15
~~, I. In eulhorlz.d to note tho book. to .how th. relee.o of thl. lien lor
th..e tB.e. Bnd .ddltlon.,
I,
I'
Name ot Ta.peyer
THOMAS W & BEVERLY L DERRICK
(;\
Resluence
817 MEADOW LN
CAMP HII,L, PA 17011-1546
'\1. '0 L,U \"\
,~,~ t\ 14'i'lt/ 2
I
Ru (\QC(O'l
last D~y for Unpaid Balance
Remlnl of Assessment
(e) (f)
10/30/2006 17345.76
************ ***~*.**********
COURT
Page UCC No.
n a n a
Tax Period
Ending
(b)
12/31/1995
..*.*** ***..***.*
RECORDING INFORMATION:
Serial No.
97-6889 FTL
Liber
n a
Kind of Tax
(II)
1040
Idendl'ylllg Number
Ie)
206-38-9578
.,tft'*""'"
Date of
Assessment
(d)
09/30/1996
**********
Piece ot Filing
Prothonotary
Cumberland County
Carlisle, PA 17013
Total $
17345.76
This notice was prepared and signed at
PITTSBURGH, PA
. on this,
the _~Bth day ot Octobe~. ..::~:.
Slgnat_ure I Tltlo _
CHIEF, SPB
(NOTIl Cerliticate of officer authoriled by law to lake acknowledgment$ i!l nol essantiallo the validity of Certificate of Release of
Feder.1 To. lien Rev, Aul, 71.468. 1971 - 2 C.B. 409)
rln t - ItECOIlDING OffiCI
Form ". (1) IRov, B.971
CA r. NO 60026\
..