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Department of the Treasury - Internal Revenue Service
Fo. ,68 (Y)(c) Notice of Federal Tax Lien
(Rev. October 2000)
Area: I Serial Number
SMALL BUSINESS/SELF EMPLOYED AREA #3
Lien Unit Phone: (800) 829-3903 230172169
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 Js 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 of Taxpayer THOMAS W DERRICK
For Optional Use by Recording Office
Residence
817 MEADOW LN
For each assessment listed below,
IMPORTANT
RELEASE
INFORIqATION:
unless notice of the lien }s raffled by the date given in column {e), this notice shall,
Tax Period Date of Last Day for Unpaid Balance
Kind of Tax Ending Identifying Number Assessment Raffling 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
Cumberland County
Carlisle, PA 17013
Total
5271.89
This notice was prepared and signed at
PITTSBURGH, PA
· on this,
the 13th dayof March 2001
Signature · , /, , Title
.... ACS 23 -01~0008
for L O 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 7%466, 1971 - 2 C.B. 409) Form 6&8(Y)(c) (Rev. 10-00)
Parr I - Kept By Recording Office CAT, NO 60025X