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I Form 666 (V) (c) Department 01 the Treaaury. Inlernal Ravanue Service
1 (Rev. Augusllgg7) Notice of Federal Tax Lien
I Dlllrlel, '" Serial Number For Opt/onnl Use by Recording O",c.
I As pr~vlded by sections 6321, 6322, end 6323 of the Internal Revenue No. q ~ - loH 5 FTl.
Code, we are giving a notice that taxes (Including Interest and penalties)
have been assessed against the following-named taxpayer. We have made
a demand for payment of this liability, but It remains unpaid. Therefore,
there Is a lien In favor of the United States on all property and rights to
property belonging to this taxpayer for the amount of these taxes, and
additional penalties, Interest, and costs that may accrue.
Name olTexpeyer
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IMPORTANT RELEASE INFORMATION: For each assessment listed below,
unlsss notice 01 lien Is rellled by the date given In column (e), this notice shall,
on the day following such date, operate as a certificate of release as defined In
IRC 6325(a),
Kind of Tax Tax Period Ended Identifying Number
(a) (b) (e)
Date 01
Assessment
(d)
'$q,e:o~
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Last Day for Unpaid Bslance of
Rellllng Assessment
(e) (f)
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iThls notice was prepared and signed at
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:the day of
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(NOTE: Certificata of officer lJuthorlzed by law to take lJckncjwfeddments Is not essontial to the validity of Notice of Federal Tax lion Rev. Rul. 71<468, 1971.2 C.B. 409)
Signature
PART 1 . KEPT BY RECORDING QFflCf
Fonn eee (Y) (e) (Rov.ll-e7)
CAT. NO 60025X
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