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Form 668 (Y)(c) <br />(Rev. February 2004) <br />3595 <br />Department of the Treasury - internal Revenue Service <br />Notice of Federal Tax Lien 2 01.3 0 3 0 5 8 <br />Area: <br />SMALL BUSINESS /SELF EMPLOYED AREA #4 <br />Lien Unit Phone: (800) 829 -3903 <br />Serial Number <br />931644213 <br />For Optional Use by Recording Office <br />1 9913713165 <br />NE <br />SHORT <br />Filed: <br />See <br />of Stake <br />DEWAYNE <br />04/17/2013 <br />-4 <br />John <br />A Gale <br />09:09 <br />- <br />Pgs: <br />AM <br />UCC <br />FTL <br />1 <br />As provided by section 6321, 6322, and 6323 of the Internal Revenue <br />Code, we are giving a notice that taxes (including interest and penalties) <br />have been assessed against the following -named taxpayer. We have made <br />a demand for payment of this liability, but it remains unpaid. Therefore, <br />there is a lien in favor of the United States on all property and rights to <br />belonging to this taxpayer <br />property xpayer for the amount of these taxes, and <br />additional penalties, interest, and costs that may accrue. <br />Name of Taxpayer DEWAYNE SHORT <br />Residence PO BOX 150 . <br />DONIPHAN, NE 68832 -0150 <br />I IMPORTANT RELEASE INFORMATION: For each assessment listed below, <br />unless notice of the lien is refiled by the date given in column (e), this notice shall, <br />on the day following such date, operate as a certificate of release as defined <br />in IRC 6325(a). <br />Kind of Tax <br />(a) <br />Tax Period <br />Ending <br />(b) <br />Identifying Number <br />(c) <br />Date of <br />Assessment <br />(d) <br />Last Day for <br />Refiling <br />(e) <br />Unpaid Balance <br />of Assessment <br />(f) <br />1040 <br />12/31/2011 <br />XXX -XX -1025 <br />05/28/2012 <br />06/27/2022 <br />3720.72 <br />Place of Filing <br />Register of Deeds <br />Hall POBOX 1692 Total <br />Grand Island, NE 68802 -1692 <br />$ 3720.72 <br />04/17/2013 WED 15:44 FAX 402 471 4429 UCC SECRETARY OF STATE <br />the 04th day of April 2013 <br />y � y <br />Hall <br />0002/004 <br />This notice was prepared and signed at CHICAGO, IL <br />, on this, <br />Signature Title <br />`� ACS SBSE <br />for G.J. CARTER - LOUIS (800) 829 -3903 <br />(NOTE: Certificate of officer authorized by law to take acknowledgment is not essential to the validity of Notice of Federal Tax lien <br />Rev. Rut. 71 -466, 1971 - 2 C.B. 409) Form 668(Y)(c) (Rev. 2 - 2004 <br />Part 1 - Kept By Recording Office CAT. NO 60025X <br />24 -00 -0008 <br />