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11/13/2012 TUE 14:14 FAX 402 471 4429 UCC SECRETARY OF 5TATE �y� Hall <br />Department of the Treasury - Internal Revenue Service <br />Notice of Federal Tax Lien � O 1�$� ���� <br />Fonn 66$ (Y)(c) <br />(Rev. February 2004) <br />Area: Serial Number <br />SMALL BUSINESS/3FsLF EMPLOYED AREA #5 <br />Lien Unit Phone: (800) 913-6050 903667512 <br />As provided by section 632t, 6322, and 6323 of the Internal Revenue <br />Code, we are giving a notFce that taxes (iecluding interest and penalttes) <br />have been auessed agaipst the following�named taxpayer. We have made <br />a demand for payment of this liability, but it remains unpaid. Therefore, <br />there i� a fien m favor of the Wuited States on all property and rights w <br />property belonging to this taxpayer for the amount of these taxes, and <br />additional penalties, interest, and cos�ts that may accrue. <br />ame <br />Residence 1513 STAGECOACH RD <br />� GRAS7D ISLAND, NE 68801 <br />For Optional Use by Recording Office <br />IMP�RTANT RELEASE INF�RMATIQN For each assessment tisted below, <br />unless notice of the Ifen is refited by the date given in column (e1, this notfce shall, <br />on the day following such date, operate as a certificate of release as defined <br />in IRC 8325iay. <br />Ta�c Period Date of Last Day for <br />Kind oE Tax Ending ldentifying Nurober Asseument Refiling <br />(a) b c) (d) (e) <br />1040 12/31/2009 XXX-XX-3010 11/22/20�0 12/22/2020 <br />1040 �12/31/2010 XXX-XX-3010 07/18/2011 08/17/2021 <br />�0o2�ooz <br />- UtC FTL <br />I <br />Pes: 1 <br />----•- ....�.� PM <br />Linpa'rd Balance <br />of Assessment <br />10785.45 <br />26148.93 <br />� <br />� <br />; <br />Piace of Filing <br />Register of Deeds <br />Hall POBOX 1692 <br />Grand Island, NE 68802=1692 <br />Total I $ <br />This notice was prepared and signed at <br />the 31st day of OCtober <br />CHICAGO, IL <br />2012 <br />36934.38 <br />, on this, <br />Signature ��� g�VENIIE OFFI CER 2 5-15 -113 S <br />� � <br />for DEBRA D PHILLIPS (479) 571-9731 <br />(NO'fE: Certiflcate of officer authorized by faw to take acknowledgment is not essential to the validity of Notice ot Federal Tex lien <br />Rev, Rul. 77-466, 1971 - 2 C.B. 409) Form 668(Y)(t) (Rev. 2-2Q04) <br />Part 1- Kept By Recording Office CAT. NO 80025X <br />