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Form 668 (Y)(c) <br />fRev February 2004) <br />Area: <br />WAGE & INVESTMENT AREA #2 <br />Lien Unit Phone: (BOO) 929 -7650 <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 Iien In favor of the United States on all property and rights to <br />property to this taxpayer for the amount of these taxes, and <br />additional penalties, interest, and costs that may accrue. <br />Name of Taxpayer HENRY A CALLEJAS <br />Residence 819 W 14TH ST <br />GRAND ISLAND, NE 68801 -3601 <br />i <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 WIC 5325(a). <br />Kind of Tax <br />(a) <br />1040 <br />1040 <br />Place of Filing <br />23. 2016 2:11FM • NE Secretary of State — UCC No. 8112 P. 2/2 <br />Tax Period <br />Ending <br />(b) <br />11953 <br />12/31/2010 <br />12/31/2012 <br />Department of the Treasury - Internal Revenue Service <br />Notice of Federal Tax Lien <br />Identifying Number <br />(c) <br />XXX -XX -5226 <br />XXX -XX -5226 <br />Serial Number <br />Date of <br />Assessment <br />(d) <br />04/22/2013 <br />07/14/2014 <br />Register of Deeds <br />Hall POBOX 1692 <br />Grand Island, NE 68802 -1692 <br />229297216 <br />Last Day for <br />Refilling <br />(e) <br />05/22/2023 <br />08/13/2024 <br />For Optional Use by Recording Office <br />N[ S.c .S t+.4. John A dsla <br />201606308 <br />UGC FTL <br />918780229 -7 P93 <br />GALLEJAS HENRY A <br />Flied; 09/23/2018 09;55 AM <br />Total $ <br />Unpaid Balance <br />of Assessment <br />(f) <br />11789.17 <br />1009.03 <br />12798:20 <br />This notice was prepared and signed at CHICAGO,, IL on this, <br />th e 13th day of September 2016 <br />Signature <br />for GRACE SANTACRUZ <br />Title <br />ACS W &I <br />(800) 829 -7650 <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 />• <br />Rev: Rul. 71 -466, 1971 - 2 C.B. 409) Fnrm FlGAI\rl /cl lAau 7 - 901141 .lam <br />