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Department of the Treasury - Internal Revenue Service
Form 668 (Y)(c)
(Rev. February 2044) Notice of Federal Tax Lien
Area: serial Number For Optional Use by Recording Office
WAGE & INVESTMENT AREA #1
Lien Unit Phone: (800) 829-7650 703763510
As provided by section 6321, 6322, and 6323 of the Internal Revenue /0 - 7L3 ?TL
Code, we are giving a notice that taxes (including interest and penalties) c-3 ?
have been assessed against the followinrnamed taxpayer. We have made ?
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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 n `
additional penalties, interest, and costs that may accrue
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Name of Taxpayer JAMIE H JOHNSON -a I
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Residence 103 STANFORD CT - 1"
MECHANICSBURG, PA 17050
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,
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d
f
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on
e
ay
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lowing such date, operate as a certificate of release as defined d
in IRC 6326(a). , ? r{9 Orlo
Kind of Tax Tax Period
Ending
Identifying Number Date of
Assessment Last Day for
Refiliing Unpaid Balance
of Assessment
(a) (b) (c} (d) (e) (f)
1040 12/31/2009 XXX-XX-7679 05/31/2010 06/30/2020 2092.03
Place of Filing
24th day of September 2010
Prothonotary
Cumberland County
Carlisle, PA 17013
This notice was prepared and signed at DETROIT, MI
the
Signature
Total 1$ 2092.03
, on this,
Title
ACS
11-00-0000
for DEBRA K, HURST (800) 829-7650
(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)
Part t - Kept By Recording Office Form 668(Y)(c) (Rev. 2-2004)
CAT. NO 60025X