Form 12474-A - Revocation Of Certificate Of Release Of Federal Tax Lien

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12474-A

Form

Department of the Treasury - Internal Revenue Service

Revocation of Certificate of Release of Federal Tax Lien

(Rev. January 2000)

Cat. No. 28891D

District

Serial Number

For Optional Use by Recording Office

I certify that we mistakenly allowed a Notice of Federal Tax Lien filed against the

taxpayer named below to operate as a Certificate of Release. I declare that the

automatic release of the Notice of Federal Tax Lien is revoked and that the lien is

reinstated as provided under Internal Revenue Code Section 6325(f)(2).

Name of Taxpayer

Residence

Tax Period

Unpaid Balance

Date of

Last Day for

Kind of Tax

Ended

Identifying Number

Assessment

Refiling

of Assessment

(a)

(d)

(f)

(b)

(c)

(e)

Place of Filing

Total

This notice was prepared and signed at

, on this,

the

day of

Signature

Title

(NOTE: Certificate of officer authorized by law to take acknowledgments is not essential to the validity of Revocation of Certification of Release of Federal Tax Lien

Rev. Rul. 71-466, 1971-2 C.B. 409.)

Part 1 - Recording Office

12474-A

Form

(Rev. 01-2000)