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Form 668 (Y)(c) <br />(Rev. February 2004) <br />5216 201602419 <br />Department of the Treasury - Internal Revenue Service <br />Notice of Federal Tax Lien <br />Area: <br />SMALL BUSINESS /SELF EMPLOYED AREA #4 <br />Lien Unit Phone: (800) 913 -6050 <br />Serial Number <br />207718616 <br />For Optional Use by Recording Office <br />NQ Sec of Sia4a Jp6n A S.1e - ULG CTL <br />IIIME <br />991677259 -4 P 1 <br />ADRIAN ESTELLA F <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 />property belonging to this taxpayer for the amount of these taxes, and <br />additional penalties, interest; and costs that may accrue. <br />Filed: 04/21/2016 01;35 PM <br />Nance of Taxpayer ESTELLA F' ADRIAN <br />Residence 1115 W ANNA ST <br />GRAND. ISLAND, NE 68801 -6602 <br />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 />Tax Period <br />Date of <br />Last Day for <br />Unpaid Balance <br />Kind of Tax <br />Ending <br />identifying Number <br />Assessment <br />Refilling <br />of Assessment <br />(a) <br />(b) <br />(c) <br />(d) <br />(e) <br />(f) <br />1040' <br />12/31/2010 <br />XXX -XX -8643 <br />08/17/2015 <br />09/16/2025 <br />87287.89 <br />1040 <br />12/31/2011 <br />XXX -XX -8643 <br />08/17/2015 <br />09/16/2025 <br />123377.93 <br />1040 <br />12/31/2012 <br />XXX-XX-8643 <br />09/21/2015 <br />10/21/2025 <br />102896.53 <br />Place of Filing <br />Register of Deeda <br />Hall POBOX 1692. Total <br />$ 313562.35 <br />Grand Island, NE 68802 - 1692 <br />This notice was prepared and signed at CHICAGO, 1z ' , on this, <br />the <br />Apr, 21. 2016 3:45FM NE Secretary of State — UCC <br />Signature . <br />08th day of April 2016 <br />Title <br />REVENUE OFFICER <br />(308) 663-6003 <br />No. 6213 F. 2/2' <br />24 -06 -2744 <br />for PATRICK J. KELLOGG <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. fiul. 71 -466, 1971 - 2 C.B. 409) Form 668(Y)0) (Rev. 2 - 2004) <br />Part 1 - Kept By Recording Office CAT No 60025X <br />