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Form 668 (Y) Department ollhe TIIBlury . Inlllnel Revenue SIIvlee
(R.v. Oclcb.r 1993) Notice of Federal Tax Lien
District Serial Number For Optional Use by R.cord/ng Of/Ie.
, . I :t.1C/5.. 10).\ I='TL
As provided by sections 6321, 6322, end 6323 01 Ihe Inlernal Revenue
Code, we are giving a notice thaI taxes (Including Interest and penalties)
have been assessed against the loll owing-named taxpayer. We have made
a demand lor paymant 01 this liability, but It remains unpaid, Therelore,
there Is a lien In favor of the United States on all property and rlghls to '"
property belonging to this taxpayer for the amount of these taxes, and Q.;.
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additional penalties, Interellt, and costs that may accrue, .:..:..:.
Name 01 Taxpayer , d" '. I (_ i.j~: . I'
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Residence .
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IMPORTANT RELEASE INFORMATION: For each assessment listed below, ,<1 ''"'Opel
unless notice of lien Is rellled by the date given in column (e). this notice shall, Cl<U ,'&'(':'4D
on the day following such date, operate as a certificate of release as defined fl.l\ ';l.';Iuu9
in IRC 6325 al.
,
Tax Period Date of Last Day for Unpaid Balance
Kind ofTax Ended Identifying Number Assessment Rellllng of Assessment
(a) (b) (c) (d) (9) (f)
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This notice was prepared and signed at
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the
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Signature '~-~ I Title ,'"
(NOTE: Certificate 01 oHlcer authorized by law to take acknowledgmenls lS not oS$fJnllallo tho validity 01 Uotlce 01 Fedoral Ta. hon
Rev. Rul 71.466,1971 ,2 C,S, 4091
Part 1 . KepI By Recording Olllce
Form 668 (Y) (Rov, 10,93)
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