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arm 668 (V) (c)
~ev, October 1993)
D.partm.nt ollh. Tr.asury . Int.rnal R.v.nu. S.rvlc.
Notice of Federal Tax Lien
llstrlct
For Opllon.,V.1 by Rlcorcllng OI/lCI
Serial Number
9:1 - "I.J6~ t: r L
As provided by sections 6321, 6322, and 6323 of the Internal Revenue
Code, we are giving a notice that texes (Including Interest and penalties)
have been 88sessed against the followlng.named taxpayer, We have made
. demand for payment of 'his liability, but It remains unpaid, Therefore,
'here Is a lien In favor of the United States on all property and rights '0
property belonging to this taxpayer for 'he amount of these taxes, and
additional penalties, Interest, and costs that may accrue,
lame of Taxpayer
lesldence
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IMPORTANT RELEASE INFORMATION: For each assessment listed below,
unless nollce of lien Is refiled 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)
Kind of Tax
(a)
Date of
Assessment
(d)
I,m
Last Day for
Reflllng
(e)
Identifying Number
(c)
lace of Filing
Total $
" :
his notice was prepared and signed at
Ie
day of
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Unpaid Balance
of Assessment
(f)
. on 'his,
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r offlcel aU~QrIZB ...b~1o';ake acknowledgmenls Is nol essentlallo lhe valldilv 01 NoUc. 01 Fld"al Tax IIln
2 C,8, 409 7;/
....' "Part1. Kept By Recording Olflce Form 668 (V) (c) (Rev, 10/93)
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