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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) 829 -3903 933321813
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 -?-
property belonging to this taxpayer for the amount of these taxes, and r �
additional penalties, interest, and costs that may accrue. &3 r
Name of Taxpayer DONALD W DAVIS JR
4 � C.J
Residence 1823 ELM ST
NEW CUMBERLND, PA 17070 -1224
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,
on the day following such date, operate as a certificate of release as defined
in IRC 3325(a ). j -2�
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 12/31/2003 XXX -XX -8877 05/05/2008 06/04/2018 21629.51
1040 12/31/2004 XXX -XX -8877 04/06/2009 05/06/2019 13992.23
1040 12/31/2006 XXX -XX -8877 04/06/2009 05/06/2019 16505.52
Place of Filing
Prothonotary
Cumberland County Total $ 52127.26
Carlisle, PA 17013
This notice was prepared and signed at DETROIT, MI , on this,
the 12th day of April 2013
Signature Title
ACS SBS E 22-00-0001
for P.A. BELTON (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. 71 -466, 1971 - 2 C.B. 409)
Form 668( (Rev. 2-200
Part 1 - Kept By Recording Office CAT. NO 60025X X