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Form 668 (Y)(c) <br />(Rev. February 2004) <br />11874 <br />Department of the Treasury - internal Revenue Service <br />Notice of Federal Tax Lien 2 01'7 0 3 9 0 <br />Area: <br />WAGE & INVESTMENT AREA #2 <br />Lien Unit Phone: (800) 829-'7650 <br />Serial Number <br />264146217 <br />For Optional use by Recording Office <br />NE <br />Sae <br />of <br />S6aie <br />Jean <br />R <br />612 <br />a - <br />MC 71_ <br />I, <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 />i <br />a <br />there is a lien in favor of the United States on all property and rights to <br />9917793524-0 Res: 1 <br />property belonging to this taxpayer for the amount of these taxes, and <br />HREUSSLER PAMELA M DECD <br />Filed: 06/14/2017 11 :02 RM <br />additional penalties, Interest, and costs that may accrue. <br />Name of Taxpayer PAMELA N HAEUSSLER DECD <br />Residence 916 W DIVISION ST <br />GRAND ISLAND, NE 68801 -6452 <br />IMPORTANT RELEASE INFORMATION: For each assessment listed below. <br />unless notice of the lien is reified 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 />Sc) <br />(d) <br />(e) <br />(f) <br />1040 <br />12/31/2015 <br />XXX -XX -7695 <br />06/06/2016 <br />07/06/2026 <br />11726.10 <br />• <br />Place of Filing <br />Register of Deeds <br />Hall POBOX 1692 Total <br />$ 11726.10 <br />Grand Island, NE 68802 -1692 <br />66 Jun.14. 2017 3:01FM NE Secretary of State — UCC <br />This notice was prepared and signed at CHIC,GO, IL , on this, <br />the 30th day of May 2017 <br />Signature <br />for GRACg /SANTACRUZ <br />Title <br />ACS W &I <br />(800) 829 -7650 <br />N'L.1053 F. 3/10 <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. Elul. 71 -466, 1971 - 2 C.B. 409) <br />Form 668(0)(c) (Rev, 2 -2004) <br />Pan I - Kept By Recording Office CAT. NO 60025X <br />7 <br />