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) <br />Form 668 c1) <br />(Rev. . February 20004) 4) <br />11874 <br />Department of the Treasury - Internal Revenue Service 9 tl ® ry n <br />! c7 <br />. Notice of Federal Tax Lien <br />Area: <br />SMALL BUSINESS /SELF EMPLOYED AREA #)4 <br />Lien Unit Phone: (800) 829 --3903 <br />Serial Number <br />245267217 <br />For Optional Use by Recording Office <br />Ng aec <br />9917788485 <br />JENSEN iled: <br />of <br />02103/2017 <br />s4.{Q .IDhn <br />-7 <br />a <br />12.15 <br />a.i <br />- <br />l: <br />pm <br />ucc Fri <br />I <br />Pgs: 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 hi 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 />Name of Taxpayer JEREMY L & KIMBERLY A JENSEN <br />Residence 2207 WOODRIDGE LN <br />GRAND ISLAND, NE 68801 -7234 <br />IMPORTANT RELEASE INFORMATION: For each assessment listed below, <br />unless notice of the lien is retiled 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 tRC 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 />1040 <br />12/31/2014 <br />12/31/2015 <br />XXX -XX -3427 <br />XXX -XX -3427 <br />11/23/2015 <br />11/21/2016 <br />12/23/2025 <br />12/21/2026 <br />5297.65 <br />30140.74 <br />Place of Filing <br />Register of Deeds <br />Hall POBOX 1692 - Total <br />Grand Island, NE 68802 -1692 <br />$ 35438.39 <br />Feb, 3. 2017 11PM NE Secretary of State — UCC <br />Vo. 9522 P. 2 <br />This notice was prepared and signed at CHICAGO, IL , on this, <br />the 12th day of January 2017 <br />Signature <br />for G.J. CARTER -LOUIS <br />Title <br />ACS SSE <br />(800) 829 -3903 <br />24 -00 -0008 <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. 4091 <br />Part 1 - Kept By Recordi Office Form 668(Y)(c) (Rev. 2 - 2004) <br />PAY nun ann1FV \ <br />