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Department of the Treasury - Internal Revenue Service
Form 668 (Y)(c)
(Rev. February 2004) Notice of Federal Tax Lien 71v 09. C "et V-7 F TL
Area: Serial Number For Optional Use by Recording Office
SMALL BUSINESS/SELF EMPLOYED AREA #4 QQ ? ??j ,p p
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Lien Unit Phone: (800) 913-6050 601909109 f
As provided by section 6321, 6322, and 6323 of the Internal Revenue
y,
Of- -7
Code, we are giving a notice that taxes (including interest and penalties)
have been assessed against the following-named taxpayer. We have made 3 'I ?qL
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.
f T
JACI WARNER
N
axpayer
ame o
Residence 699 BURNTHOUSE RD
CARLISLE
PA 17013
, C4
..
NT RELEASE INFORMATION: For each assessment listed below, tai
e of the lien is refilled by the date given in column (e), this notice shall,
F
following such date, operate as a certificate of release as defined
IRC
5(a).
Tax Period Date of Last Darrfor Unpaid Balance
Kind of Tax Ending Identifying Number Assessment Refilling of Assessment
(a) (b) (c) (d) (e) (f)
1040 12/31/2001 XXX-XX-3499 05/20/2002 06/19/2012 11001.06
1040 12/31/2003 XXX-XX-3499 11/08/2004 12/08/2014 13601.90
1040 12/31/2005 XXX-XX-3499 05/29/2006 06/28/2016 4982.01
Place of Filing
Prothonotary
Cumberland County
Carlisle, PA 17013
Total I$ 29584.97
This notice was prepared and signed at
DETROIT, MI
the 25th day of November 2009
, on this,
Signature f?. R. REVENUE OFFICER 24-06-1710
for DEBRA RHYMES (816) 966-2429
(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 I - Kept By Recording Office CAT. NO 60025X