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Fof;rt ~~ DoUartmenr of the Traesury - internal Reve~iue Service <br />~ ~Ae~:S~~ram~.~,s,n;~_: ; Native of :Federal Tax Lien Under Internal Revenue Laws <br />Disitict - Serial Number Foi opronnl uae or Fxortlrnv orOCe <br />t%Iticift`Z 4. ~ 4104 ~i <br />As provided by sections 6321, 5322, and 6323 of the Internal Revenue Code, <br />notice is given that taxes (including interest and penalties) have been assessed <br />against the following-named" taxpayer. Demand for payment of this liability has ~ <br />been made. but it remains unpaid. Therefora, there is a lien in favor of the United ~ <br />States on all property and rights tc property belonging to this taxpayer for the S 2 ~ U ~f ~ 4 ~ 3 <br />amount of these taxes, and additional penalties, interest, and costs that may <br />accrue. <br />Name or Taxpayer <br />~- <br /> <br />Kkrd of TsY ~ <br />UI <br />Ta: Per!od Ended <br />(DJ <br />lbte of Assessment ', <br />(cJ <br />IdentNying Numl»r <br />Cd) Unpaid Balance <br />of Assessment <br />(~) <br /> I <br /> <br />y <br />1 { <br />I <br /> <br />~ ~ <br />i <br />Place of Flling ;; ~ ,. i ._ ~ y?' ,~ y j :.~: <br />~Ut~'?t t J-. ~ - <br />Total <br />` <br />:~~ <br />~~ <br />~ i = <br />~~".,_ <br />_r ~._3 yam. :_. ., ..~, <br />&. . ~ . , <br />r <br />- <br />T„~. , <br />Thisnotice was prepared and signed at ~= ~:ici ~~~~_-~''~~s ~~= =~-n ~ _, on this. <br />the Gf~~h daYOf t.~`T -.19 ~'~ <br />Signatur Title <br />:~ ~l - P:: ~ - - <br />(NOt~: Cartr/icate o1 ~Ilic e~ eUlhoriz?tl Gy law .n :ako eckno'~vlsdq ni~nts is n0[ a..senfia/ to tM1e velltl,ty Of NO(ICe of <br />FWMaI Tea Limon G.C"A9. 26.119, )950.1, C_B- 125_) <br />Part 1 - To be kept by recording office Poem i368 (Rev. a~8) <br />i <br />y <br />