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I <br />M - ~~:~~ = ~: 'Department of the Treasury - Int~tnal Hsvenw Service <br />i Farm W ~-.:'' ~.r~` <br />' !~ Fem., ~ ; : Nye Tax lien Under Internal Ri <br />District _ <br />iti:. i3* ~. ~ j.,~,.....~.. <br />Nucnt>Rr Fa.opr~ana <br />-ubi is .t :tih'-. t3 ~J ~ <br />laws <br />M provided uy ~: 6312, and 632'd of tha internal F~venw Cotlb, I """ <br />ROllte is°-giVln t taxes(1including intsnst.and pepaltiea- hWe-beitt i - <br />aeeaaed sy~inst'tftie foNovrin9'nembd` t~WY1t. Demand for payment of , <br />thla 11at7pHy bas been made, but it romaina tnq-atd. Therefore, thsro is a lien ~- <br />infavor ottht Unilld=StatN on aN prty aed~ighta to propertY.betonging ' ~ --~' ' 1 ~ ~ 1 <br />to thU taxpayer ftir'-lha'emourH' at t eas thxes, ahtf additiioona~ penattiea, <br />inte(est; and costathat may accrue. i <br />tJame of i'axpayer <br />,,der :;tttater ..erv1C~ ., r itt~i2h'i"ic, 1rtC icor~ <br />c~esae~ <br />aJG ~u5e. ~Lf~{ic- i'~„T`t, i{Ltc;.7 i _ <br />ItfF'ORTAN7 REiE/SE I`FOFiMAT[+3tii; W+th respect to eactraeeessretent: fisted below,- unless. - . <br />noECe. ~I ties IE ryliled 6y 11» uald givgR M°t CgtUn4n {°-), thlg flbtlG6 5heff, dtt i#te day follpWin9- <br />. sucn ae4, ~oerele es a ct>rths:au a:,re;t~ese :~s tie~n(«f~*ifiC"&3~5.ia): ~ ., <br />Tax Perfad t flateot Vst Day for T---Ur~p~tl pihr~cy -- <br />1tMd W FtftY ~ EI-dad identltytng fkxn6er~' A~NnipMFlt 1 HetiUng ~ of A~n~rt <br />' } <br />t <br />{ <br />{ { <br />~ I <br />t ~- <br />__ ! ~ - <br />. ,, y <br />ti-~ -- _ <br />,+ i <br />,:, -e <br />,. ! ,__ <br />mss- ;~ ; <br />§ a <br />,, <br />_ ~;' _ __ i .f _ .. __ <br />PtaceoiFgt~ ~ ~ ~ <br />~iF*~3et~3 of e ; s' ~, J <br />a„ t ~ £l.t `i ~ p ~ ~ `:.', l ~ ! .>ttfs ~ cr . _ ~ .._ : ~ v xotai rj- <br />TlttS tigt~,XEt waB(i#8parea arM Stgrrest at ___ . _ ~d';sd - tom. t)rn5~ ~_._ ~ - _ - - ._..~ <br />„ OR this; <br />xtati; '~Ert?xa~~ct` <br />the dayoi______._~__._..,. 19 _~„__.._....._..,.__. , , , ~ .~ .. ~ ~ = <br />.. __._ .-T..~... __ ~_ _......_ <br />_~,r ....-.-~.---m-..._.__ - _._. <br />~~~~c`~. ~ ~' TrCte <br />MOTEL CbtaiodWNawxaasarrs~dhM•iaw-h:a~ts~rawaxncrt esItar to sres wafarkryW Natiaedf•erlegr iaciien <br />A~ Avi, Tv ?60. ii17hR. C~ +ia9F <br />Per. ? ._ T`o ba ih'st3t ~~ .-3§rtgt~.rYfEt~ porm 5~Ni(C1 ~Htn+.,~-83~-- , <br /> <br /> <br />