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Department of the Treasury - Internal Revenue Service
Form 668 (Y)(c) Notice of Federal Tax Lien
(Rev. February 2004) NO CA-5118 FTT-
Area: Serial Number
SMALL BUSINESS/SELF EMPLOYED AREA #2
Lien Unit Phone: (800) 829-3903 566624909
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
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.
ame
COOK
Residence 114 S WEST ST APT 3
CARLISLE, PA 17013-2871
For Optional Use by Recording Office
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IMPORTANT RELEASE INFORMATION: For each assessment listed below,
unless notice 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
in IRC 6325(a).
Tax Period Date of Last Day for
Kind of Tax Ending Identifying Number Assessment Refilling
(a) (b) (c) (d) (e)
1040 112/31/2003 XXX-XX-4258 112/24/20071 01/23/2018
1040 12/31/2004 XXX-XX-4258 12/24/2007 01/23/2018
Place of Filing
Prothonotary
Cumberland County
Carlisle, PA 17013
Unpaid Balance
of Assessment
6445.87
7566.53
Total 1 $ 14012.40
This notice was prepared and signed at DETROIT, MI
the 21st day of July 2009
, on this,
Signature A ACS tle
22-00-0008
for MICHAEL W. COX (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. 71-466, 1971 - 2 C.B. 409) Form 668(Y)(c) (Rev. 2-2004)
Part 1 - Kept By Recording Office CAT. NO 60025X