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form 668 (V)
Department of Hh,) Ttea.3ur'l . Inlsrl'\al A4'J,11ue Survl':.
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Notice of Federal Tax lIen
IDistrlct \ Sanal Numbar FrH ~JJ U,,, 0'1 RtJCQrdiflq Offlc,
jJ 9'-1- s-"5-3
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I Aa provided by sections 6321, 6322, and 6323 01 1M Inlernal Revenue
Code, we are giving a notice that taxes (Including Interest end penalties)
I have been assessed against the lollowlng-named taxpayer. We have made
. demand lor payment 01 this lIablllly, but It remains unpaid. Therefore,
th.re Is a lien In lavor 01 the United States an all property and rights to c:'l
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property belonging to this taxpayer lor the amount 01 these laxGS, and ...
additional penalties, Interest, and costs that may accrue.
Name of Ta~payer j'
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\Residence , "
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, ,19.00 ...
IMPORTANT RELEASE INFORMATION: For each assessment listed below,
unless nolice at lien is rallied by the date given in column (e), this nolice shall, C}L:JI Db 7 S J9.J...
on Ihe day lollowing such date, operate as a certificate 01 release as defined
In IRC 6325'a), R# 1l.R~I(;
Tax Period Oeteol Last Day lor Unpaid Bal.nce
Kind of Tax Ended Identifying Number Assessment Rellllng of A.....m.nt
(a) (b) (c) (d) (e) (f)
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Place of Filing
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;' Total $
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iThiS notice was prepared and signed at
. on this,
:the
. day of
.19_.
Signature
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HOTE: I~,,,!,i ,:.p.! G' c,trt.Jf ,IIJli'c!r:!H.-j b'( i FI "J !'~'.' 1
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Form 668 (V) (Rav 10,93)
Part 1 ~ Kept 0,/ rl>"':'~rdln':J Office
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