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Form 668 (Y 041 <br />tRev. February 20041 <br />5216 <br />. <br />Department of the Treasury - Internal Revenue Service 0 0 <br />Notice of Federal Tax Lien <br />Area: <br />WAGE & INVESTMENT AREA #2 <br />Lien Unit Phone: (800) 829 -7650 <br />Serial Number <br />176749515 <br />For Optional Use by Recording Office <br />As provided by section 6321, 6322, and 6323 of the Internal Revenue <br />N E Sec =r <br />54a4. <br />,o" <br />n n.1 <br />' <br />uce <br />Gn <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 Hen In favor of the United States on all property and rights to <br />property belonging to this taxpayer for the amount of these taxes, and <br />g9157619e0 <br />-6 <br />P 1 <br />additional penalties, interest, and costs that may accrue. <br />DAVIS BRUCE L <br />Filed: 10{ 06!2015 12:22 PM <br />Name of Taxpayer BRUCE L DAVIS <br />Residence 1104 KENNEDY DR <br />GRAND ISLAND, NE 68803 <br />IMPORTANT RELEASE INFORMATION: For each assessment listed below, <br />unless notice of the lien is refiled by the date given in column (8), this notice shall, <br />on the day following such date, operate as a certificate of release as defined <br />in IRC 6325(a). <br />Tax Period <br />Date of <br />Last Day for <br />Unpaid Balance <br />Kind of Tax <br />Ending <br />Identifying Number <br />Assessment <br />Refing <br />of Assessment <br />(a) <br />(b) <br />(c) <br />(d) <br />(e) <br />(f) <br />1040 <br />12/31/2012 <br />XXX -XX -4852 <br />04/06/2015 <br />05/06/2025 <br />1040 <br />12/31/2012 <br />XXX -XX --4852 <br />04/06/2015 <br />05/06/2025 <br />13781.96 <br />Place of Filing <br />Register of Deeds <br />Hall POBOX 1692 Total <br />$ 13781.96 <br />Grand Island, NE 68802 -1692 <br />4 Oct. 6. 2015 3:29PM NE Secretary of State — UCC <br />This notice was prepared and signed at CHICAGO, IL <br />the <br />16th day of September 2015 <br />Signature <br />for GRACE SANTACRUZ <br />Title <br />ACS W &I <br />(800) 829 -7650 <br />H. 3022 F. 2% <br />, on this, <br />14 -00 -0000 <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. Rul. 71 -466, 1971 - 2 C.B. 409) Form 669(Y)(c) (Rev. 2 - 2004) <br />Part t _ Kept By Recording Office CAT. NO 60025X <br />