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BUREAU OF COMPLIANCE -
DEPARTMENT OF REVENUE
Po BOX 280948 REVK-1 59(12-12)REVOOOK9 DOCEXEC
HARRISBURG PA 17128-0948
CERTIFIED COPY OF LIEN[11 A Y 2 7
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY,
CUMBERLAND COUNTY PENNSYLVANIA
PREMIER FITNEHNIMLVAINIA EIN:................................................23-2944091/000
401 S FRONT ST Notice Date:....................................April 20,2014
WORMLEYSBURG PA 17043- 1342 Notice Number:...............................749-567-014-041-5
To the Prothonotary of said court: Pursuant to the laws of the
Commonwealth of Pennsylvania, there is herewith transmitted a certified
copy of a lien to be entered of record in your county.
1 2 3 4 5 6
TAX TYPE ACCOUNT ID TAX TAX TAX TOTAL
PERIOD PERIOD
BEGIN END
SALES 80927840 02-01-12 02-29-12 0.00 58.26
SALES 80927840 03-01-12 03-31-12 0.00 40.31
SALES 80927840 04-01-12 04-30-12 0.00 12.37
SALES 80927840 07-01-12 07-31-12 0.00 67.47
SALES 80927840 08-01-12 08-31-12 0.00 38.51
SALES 80927840 09-01-12 09-30-12 0.00 12.60
SALES 80927840 05-01-12 05-31-12 0.00 93.07
TOTAL: 0.00 322.59
FILING FEE(S): 21.50
SATISFACTION FEE(S): 10.00
SETTLEMENT TOTAL: 354.09
INTEREST CALCULATION DATE: 07-14-14
The undersigned,the Secretary of Revenue or authorized delegate of the Commonwealth of Pennsylvania, certifies this to be a true and correct copy
of a lien against the above-named taxpayer for unpaid tax, interest, additions or penalties therein due from such taxpayer and which, after demand for
payment thereof, remains unpaid. The amount of such unpaid tax, interest, additions or penalties is a lien in favor of the Commonwealth of
Pennsylvania upon the taxpayer's property-real,personal or both-as the case may be.
April 20,2014
'SJCPeARY OF REVENUE DATE
(OR AUTHORIZED DELEGATE)
PART I -TO BE RETAINED BY RECORDING OFFICE
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