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Deportment of Ihe Troasury . Inlornol Revenuo Service
Notice of Federal Tax Lien
District
Sonal Numbor
IIII 1".11'110111"
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l AI provided by eectlons 6321, 6322, and 6323 of the Inlernol Revenue
Code, we are giving a nollce that taxes (Including Interest and penaltlas)
hIve been aueleed agalnelthe following. named taxpayer. We have mada
. d.mand lor plymant 01 Ihll lIablllly, bul II remains unpaid. Therelore,
th.r. II I lI.n In Ilvor 01 Ihe Unllad Slalas on all proparty and right I to
prop.rty bllonglng to thll Ilxpayar lor tha amounl 01 thasa taxea, and
Iddltlonll p.naltlal, Interlll, and COllllhlt may accrua.
Name 01 Taxpayer II (',Illrll :',III,q... 01.' .,111,1",1.11'
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IMPORTANT RELEASE INFORMATION: For each assessment listed below.
unless notice of lien Is refiled by the date given In column (fl). this notice shall.
on Ihe day following such date. operate as a certificate of release as defined
InIRClt6S25a,<I,I' I., 011,:1 Cd 1'11\1 11'\11 iI'l ..1'. ,"..
Tax Period Data 01
Ended Identifying Numbar Assessment
(b) (e) (d)
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,"~d\ "77,)'1'8
Kind of Tax
(a)
q;(11 ;'}/,:,L.j.5'f
Last Day for Unplld Slllnel
Rollllng of A.....m.nt
(e) (0
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40-/U'~J. ::31
Place 01 FIling F'r-.,th",.,.,ta,-y
(:LJlilbe,"'1 alld (f)unl;'f
(at-lislt?1 F'A lrnl:~l
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I F'tll I ,'.de I f,h 101' PA.
IThls notice was prepared and signed al _
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lhe ,', day of .. . ,19_.
, on Ihls,
rtle
C.h I 1::' f. ~). f-'. U.,
(NOTE: Cljrlillc,lle 01 oHICf'r .1LJlh()ril~d by 1,IW 10 l;\~o) ac~n,)wlljdal'lf.I1I', I'; II'll e~iSI!f111,jllr) lh(! vnlidl1y 01 Notice 01 Federal Tll:-C lien
Rev Rul /1.466, 1'l!1 :' C 8 40'J)
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ParI 1 . Kept By Recording Office
Form 668 (V) (Rev. 10.931
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