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Form 668 (Y)(c)
(Rev. February 2004)
11883
Department of the Treasury - Internal Revenue Service
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 819848511
7
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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, . ,
there Is a lien in favor of the United States on all property and rights to ?m
property belonging to this taxpayer for the amount of these taxes, and c1a T
additional penalties, interest, and costs that may accrue. ---
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77
Name of Taxpayer DAVID J BURGESS
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Residence 3524 SEPTEMBER DR APT 2 °? .^.
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CAMP HILL, PA 17011-5062 I
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IMPORTANT RELEASE INFORMATION: For each assessment listed below,
unless notice of the lien is refilled by the date given in column (e), this notice shall,
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on the day following such date, operate as a certificate of release as defined
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n I 6325(a). Air
Tax Period Date of Last Day for Unpaid Balance
Kind of Tax Ending Identifying Number Assessment Refilling of Assessment
(a) (b) (c) (d) (e) (f)
1040 12/31/2008
1 XXX-XX-4851 05/09/2011 06/08/2021 76733.41
Place of Filing
Prothonotary
Cumberland County
Carlisle, PA 17013
Total 1$ 76733.41
This notice was prepared and signed at DETROIT, MI
the 07th day of October 2011
, on this,
Signature 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 1 - Kept By Recording Office CAT. NO 60025X