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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 125919014 �l
As provided by section 6321, 6322, and 6323 of the Internal Revenue 1 y" 62-
Code,
2-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, -
additional penalties, interest, and costs that may accrue. Mrn Pf
Name of Taxpayer CHARLENA BELCHER -4 , ,w
CDc'
ResidenceCD--n
122 S SECOND ST APT 2 ;---
CD
WORMLEYSBURG, PA 17043-1312 ' 00 C-) t
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, _41 - j
on the day following such date, operate as a certificate of release as defined f
in IRC 6325(a). —7/-_�
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)
1040 12/31/2009 XXX-XX-7938 12/16/2013 01/15/2024 26744 . 16
1040 12/31/2010 XXX-XX-7938 12/02/2013 01/01/2024 13177 . 12
Place of Filing
Prothonotary
Cumberland County Total $ 39921 .28
Carlisle, PA 17013
This notice was prepared and signed at DETROIT, MI , on this,
the 21st day of October 2014
Signature /";"�✓-�. ACS SBSE 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(Y)(c) (Rev. 2-2004)
Part 1 - Kent By Recordin¢Office