Tax Lien Notice Form

TAX LIEN NOTICE FORM

Notice Summary

Taxing Authority:

Lien Number:    Date of Notice:

Taxpayer Identification

Individual/Sole Proprietor    C Corp    S Corp    Partnership

Trust/Estate    LLC    Other:

Social Security Number (SSN):    Employer Identification Number (EIN):

Lien and Assessment Details

Assessment Date:

Recording and Effect of Lien

County or Recording Jurisdiction:

Date Recorded (if recorded):

This lien secures payment of the tax liabilities identified above, together with interest, penalties, and collection costs as authorized by law. If not satisfied, the lien may be enforced against the property described herein by levy, sale, or other remedies permitted by statute and regulation.

Payment and Release

Amount required to release the lien in full as of the date of this notice:

Upon receipt of full payment, the taxing authority will execute a release of lien and record it in the appropriate jurisdiction. Any partial payment may affect the balance but may not prevent collection action consistent with law.

Certification and Acknowledgment

By signing below, the undersigned taxpayer certifies, under penalty of perjury, the truth and accuracy of the following statements:

1. I am the taxpayer or an authorized representative of the taxpayer identified on this form and I am competent to execute this acknowledgment.
2. I have received notice of the tax lien described above and understand the amount, property affected, and potential enforcement remedies for nonpayment.
3. I understand that the taxing authority may record or has recorded this lien in the identified jurisdiction and that recording may affect title to the property.
4. I acknowledge that providing false information in connection with this form may subject me to civil or criminal penalties under applicable law.

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