HomeMy WebLinkAbout01-1697 FX
499
Department of the Treasury - Internal Revenue Service
Form 668 (Y)(c) Notice of Federal Tax Lien
(Rev. October 2000)
Area: Serial Number For Optional Use by Recording Office
SMALL BUSINESS/SELF EMPLOYED AREA #3 )ft.f7 ,. 7L
Lien Unit Phone: (800) 829-3903 230172169 61-
As provided by section 6321, 6322, and 6323 of the Internal Revenue
Code, we are giving a notice that taxes (including interest and penalties)
have been assessed against the following-named taxpayer. We have made () 0 (---,
a demand for payment of this liability, but it remains unpaid. Therefore, c - --I;
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there is a lien in favor of the United States on all property and rights to -on] J:Jp ....,
property belonging to this taxpayer for the amount of these taxes, and mrn :u
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additional penalties, interest, and costs that may accrue. ...,-,(?
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Name of Taxpayer THOMAS W DERRICK (2C -0 " : ::r~
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Residence ~ ~" 5;
817 MEADOW LN \0 -<
CAMP HILL, PA 17011-1546 I~ PCjD CftV
IMPORTANT RELEASE INFORMATION: For each assessment listed below, U /4LO*
unless hotice of the lien is refiled by the date given in column (e), this notice shall, @
on the day following such date, operate as a certificate of release as defined /6Cr J-ff
in IRe 6325(a).
Tax Period Date of Last D?; for Unpaid Bala!!ce
Kind of Tax Ending Identifying Number Assessment Refi 109 of Assessment
(a) (b) (c) (d) (e) (f) ,
1040 12/31/1997 206-38-9578 09/21/1998 10/21/2008 5271.89
Place of Filing
Prothonotary Total $
Cumberland County 5271.89
Carlisle, PA 17013
This notice was prepared and signed at
PITTSBURGH, PA
, on this,
13th day of March
2001
the
,
Signature
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Title
ACS
23-01-0008
for L G DOWD ! (800) 829-3903
(NOTE: Certificate of officer authorized by law to take acknowledgment is not essential to the validity of Notice of Federal Tax lien
Rev. Rul. 71 c466, 1971 c 2 C.B. 4091
Form 668(Y)(c) (Rev. 10-001
Part I - Kept By Recording Office CAT. NO 60025X
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