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Department of the Treasury. Internal Revenue Service
Form 666 IV) Ic) Notice of Federal Tax Lien
(Rev, October 1993)
District Serial Number For Optional US" by R"co,dlng Olllce
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As provided by sections 6321, 6322, and 6323 of the Internal Revenue ( ). S[.JO ~TL
Code, we are giving a notice that taxes (Including Interest and penalties)
have been assessed against the followlng.named taxpayer. We have made
a demand for payment of this liability, but It remains unpaid. Therefore,
there Is a lien In favor of the United States on all property and rights to
property belonging to this taxpayer for the amount of these taxes, and ,,,.-,
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additional penalties, Interest, and costs that may accrue. .."
Name of Taxpayer .....:
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Residence c,
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IMPORTANT RELEASE INFORMATION: For each assessment listed below. ""
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unless notice of lien is refiled by the date given in column (e). this notice shall. ll'lc':-'i<:i
on the day following such date. operate as a certificate of release as defined
in IRC 6325(a). ~.......t\'1"~~~~1 Rti ~'1(i4l.
Tax Period Date of Last Day for UnpaId Balance
Kind of Tax Ended Identifying Number Assessment Reflllng of Assessment
(a) (b) (e) (d) (e) (f)
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Place of Filing
Total $
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This notice was prepared and signed at
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the
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day of
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Signature
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,f luthor zed hy- IIlW '0 take acl.iT'io'!\ledgm'''ts IS not t"lnlial 10 the vllldltv 01 Noth:. of Fed".1 Tu lI.n
4091
Part 1 . Kept By Recording Olllce
Form 668 (V) (c) (Rev 10:93) ...