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Form 668 (Y)
(R.v. October 19~JI
Depertment 01 the Treesury . Inl~rn.1 Revenue Service
Notice of Federal Tax Lien
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'District
Serial Number
For Optional Us. by R.cording 0lllC9
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As provided by sections 6321, 6322, end 6323 of the Internal Revenue
i Code, we are giving a notice that taxes (Including Interest and penalties)
'have bean assessed against the followlng.namad taxpayer, We have me de
a demend for payment of this liability, but It remains unpaid. Therefore,
there Is a lien In lavor of the United States on all property and rights to
[ property belonging to this taxpayer for the amount of these taxes, and
r additional pen alii as, Interest, and costs that may accrue,
iName of Taxpayer i.,.' li.li:,.
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IResidence
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Kind 01 Tax
(a)
Identifying Number
(e)
Date of
Assassment
(d)
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Last Day for Unpaid Balance
Aeflllng of Assessment
(a) (f)
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IMPORTANT RELEASE INFORMATION: For each assessment listed below,
unless notice 01 lien is rellled 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 6325 a .
Tax Period
Ended
(b)
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This notice was prepared and signed at
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Signature
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(NOTE: Cerll!lclIlo 01 olhcc, authorized by law 10 take .1ckno,^,ll'c:1g~enIS 15 nolIJsscnllalto Iho ....alidltv 01 Nollce 01 Federal Tal( lien
A(!.... nul 71..Hj6. 1971 .2 C 0 .s09)
Part' , Kept By Recording Office
Form 668 (Y) (Rev. 10-93)
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