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12/29/2011 T8U 15:13 FAx 402 471 4429 UCC SBCRSTARY OF STATS yy� 8a11 (�002/002 <br />V <br />Forjn 668 (Y)(t) <br />{Rev. February 20041 <br />3 <br />Department of the Treasury - Internal Revenue Service <br />Notice of Federal Tax �.ien 2 ��.10 9 8 9$ <br />Area: Seris�l Number <br />SMA.LL BUSYNESSfSELF EMPLOYED AREA #4 <br />Lie� Unit Pho�e: (eo0) 913 837503211 <br />As provided by section 6321, 6322, and 6323 of the Interital Revenue <br />Code, we are giving a notice that taxes (including interest and penaldes) <br />have been auessed against the. fo{lovaing-named taxpayer. We have made <br />a demand for payment of this liability, bat it remains unpald. ThErefore, <br />there is a lien in favor of the tlnited States on aQ property and ri�ts to <br />property 6elong8ng to this taxpayer for the amoant of these taxes, and <br />additional penalties, interest, and costs that may accrue. <br />ame <br />Residence p0 BOX 150 � <br />DONIPHAN, NE 68832-0150 <br />NE See ot Sia}p Jehn p po� - UCC FTl � <br />99 11680800-8 p� � ' <br />Fi�ed 2g Zj 01t 09:35 AM <br />IMPORTANT RELEASE INFORMATION: For each assessment Iisted below, <br />unless notice of the lien is refiled by the dat� given in column (e1. this notice shall, <br />on tHe day following such data, operate as e certificate of release as defined , <br />in IRC 6325(a). <br />Tax Period Date of Last Day for <br />Kind of Tax Ending ldentifying Number � Aueument Refiting <br />(a) (b) (�) d) 4�) <br />io4o Za/3i/aoo9 xx�c-xx-io2s ia/os/2oii O1j04j2022 <br />1040 12/31/2010 XXX-XX-1025 12/05/2011 Ol/04/2022 <br />Place of Flling <br />Register of Deeds <br />Hall POBOX 1692 • <br />Grand Island, NE 68802-1692 <br />Total <br />lJnpaid Baiance <br />of Assessm�nt <br />3395.01 <br />11640.62 <br />15035.63 <br />This notice was prapared and signed at - CHICAGO, IL <br />� . 2 Oth day of December . 2 O11 <br />, <br />, c+n this, <br />Signature � Title <br />. REVENUT. ORFICER,_� . , . 24-10-1720 <br />for DANIELLE L�NIUELL �. (402) 473-4675 x2912 <br />(NOTE Certificeta of officer authorized by law to teke acknowlsdgment is Flat essential to the validity of Odot{ce of Federal Tax lien <br />� Rev. Rul. 71-466. 1971 - Z C.B..409) • . . '� � � " Form 668(Y)(c) (Rev.•�-2004) <br />' � " � _ � � Part 1 - K�t By RewrdMg.ONice � ' • CAT NO 60025X <br />