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Form 668 (Y)(c) Department of the Treasury - Internal Revenue Service
(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 118225514
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, c `
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
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additional penalties, interest, and costs that may accrue.
Name of Taxpayer ROGER KAPLAN
Residence c�
112 S 16TH ST tv ` 'r
CAMP HILL, PA 17011-5505
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, —r
on the day following such date, operate as a certificate of release as defined vhf -S' �'Gt
in IRC 6325(a). et-77 3`
Tax Period Date of Last Day for Unpaid Balance
Kind of Tax Ending Identifying Number Assessment Refiling of Assessment
(a) (b) (c) (d) (e) (f)
6702A 12/31/2012 XXX-XX-9843 04/07/2014 05/07/2024 5000 . 00
Place of Filing
Prothonotary
Cumberland County Total $ 5000. 00
Carlisle, PA 17013
This notice was prepared and signed at DETROIT, MI
on this,
the 04th day of September 2014
SignatureTitle
REVENUE OFFICER 22-06-2624
for JAKOB A 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. Rut. 71-466, 1971 -2 C.B. 409) Form 668(Y)(c) (Rev, 2-2004)
Part 1 -Kept By Recording Office rAT Kin Ann)Av