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Department of the Treasury - Internal Revenue Service
Form 668 (Y)(c)
(Rev. February 2004) Notice of Federal Tax Lien
Area: Serial Number For Optional Use by Recording Office
SMALL BUSINESS/SELF EMPLOYED AREA #2
Lien Unit Phone: (800) 913-6050 751146211 /f _.'')33
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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, =M
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there is a lien in favor of the United States on all property and rights to ' 'r,D
property belonging to this taxpayer for the amount of these taxes, and tom; cn
additional penalties, interest, and costs that may accrue. .°? *a' ??
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Name of Taxpayer CAPITAL CITY JEWELERS INC cw.. ,
a Corporation ':n •---171
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Residence 3401 HARTZDALE DR STE 131
CAMP HILL, PA 17011-7238
TANT RELEASE INFORMATION: For each assessment listed below,
otice of the lien is refiled by the date given in column (e), this notice shall,
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day following such date, operate as a certificate of release as defined
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Ta x Period Date of Last Day for Unpaid Balance
Kind of Tax Ending Identifying Number Assessment Refiling of Assessment
(a) (b) (c) (d) e) (f)
941 06/30/2008 03-0408672 09/29/2008 10/29/2018 3043.29
941 09/30/2008 03-0408672 12/29/2008 01/28/2019 2506.99
941 12/31/2008 03-0408672 04/06/2009 05/06/2019 1105.06
Place of Filing
Prothonotary
Cumberland County
Carlisle, PA 17013
Total 1 $ 6655.34
This notice was prepared and signed at
the 07th day of February
DETROIT, MI
2011
, on this,
Signature c?- Title
REVENUE OFFICER 22-06-1418
for JAKOB PEDERSEN (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. 409) Form 668(Y)(c) (Rev. 2-2004)
Part I - Kept By Recording Office CAT. NO 60025X
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