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Department of the Treasury -Internal Revenue Service
Forrfn 668 (Y)(c) Notice of Federal Tax Lien
(Rev: February 20041
Serial Number For Optional Use by Recording Office
Area:
SMALL BUSINESSjSELF EMPLOYED AREA #2
Lien Unit Phone: (800) 913-6050 717879810
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evenue
As provided by section 6321, 6322, and 6323 of the Internal
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, ~ ~'~,` ~' ' -~ k
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there is a lien in favor of the tf nited States on all property and rights to f~ ~-=-
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property belonging to this taxpayer for the amount of these taxes, and fz i°"' .~ ~
additional penalties, interest, and costs that may accrue. ~~~~ ~' ~;'a,
Name of Taxpayer MARY E HOOPER
CRIMSON FROG COFFEEHOUSE ~- .~:
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Residence 1104 CARLISLE ROAD " ;.
CAMP HILL, PA 17011-6203
IMPORTANT RELEASE INFORMATION: For each assessment listed below,
unless notice of the lien is refiled by the date given in column le), this notice shall,
on the day following such date, operate as a certificate of release as defined ~g.~~ ~o~ tG~'
in IRC 63251a1. ,~s'/a '
Tax Period Date of Last Dayy far unpaid Balance
Kind of Tax Ending Identifying Number Assessment Refiling of Assessment
(a) (b) (c) (d) (e) (~
941 06/30/2010 20-1551268 10/04f2010 11/03/2020 280.66
Place of Filing
Prothonotary
Cumberland County
Carlisle, PA 17013
Total ~ $
280.66
This notice was prepared and signed at DETROIT, MI
the 04th day of November 2010
on this,
Signature Title
~~` REVENUE OFFICER 22-06-1418
for JAKOB PEDERSEN c' (717) 777-9621
(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. 4091 Form 668(Y)(c) (Rev. 2-2004)
Part 1 -Kept sy Recording Office CAT. NO 60025X