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08/28/2000 16:05 FAX 14024714429 NEBRASKA UCC <br />I 109 Department of the Treasury - Internal Revenue Service <br />Form 668 (Y)(c) Notice of Federal Tax Lien <br />iAev. August 1997) <br />District Serial Number <br />MIDWEST 390037231 <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 lability, 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 />Name of Taxpayer KEITH A JORGENSEN <br />Residence 821 W OKLAHOMA <br />GRAND ISLAND, NE 68801 -6754 <br />fa004/004 <br />For Optional Use by Recording Office <br />WE suc of Si-i111111INkIkNilll�llllll <br />k11111111111111 P95 , <br />9900078947 <br />JORGENSEN KEITH R <br />Filed G9l2912000 1029'iM <br />IMPORTANT RELEASE INFORMATION! For each assessment listed below, <br />unless notice 5f the lien is refiled by the date given in column (e), this notice shall, <br />on the day following such data, operate as a certificate of release as defined <br />in IRC 6325(x). <br />Tax Period <br />Date of <br />Last Da 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 />941 <br />09/30/1998 <br />47- 0666059 <br />12/07/1996 <br />01/06/2009 <br />4739.15 <br />941 <br />12/31/1998 <br />47- 0666059 <br />03/29/1999 <br />04/28/2009 <br />328.06 <br />941 <br />06/30/1999 <br />47- 0666059 <br />09/06/1999 <br />10/06/2009 <br />2433.56 <br />941 <br />09/30/1999 <br />47- 0666059 <br />12/20/1999 <br />01/19/2010 <br />7361.25 <br />941 <br />12/31/1999 <br />47- 0666059 <br />03/20/2000 <br />04/19/2010 <br />7578.69 <br />941 <br />03/31/2000 <br />47- 0666059 <br />06/19/2000 <br />07/19/2010 <br />7234.88 <br />Place of Filing <br />Register of Deeds Total <br />$ <br />Hall POBOX 1692 <br />29675.79 <br />Grand Island, NE 68802 -1692 <br />This notice was prepared and signed at MILWAUKEE, . WI , on this, <br />the 21st day of August 2000 <br />Signature Title Revenue Officer 39 -01 -2339 1 <br />f (308) 385 -6546 <br />(NOTE: certificate of officer authorized by law to take acknowledgment is not essential to the validity of Notice of Federal Tax lien i <br />Rev. Rul. 71-466,1971 • 2 C.B. 409) Form 668(Y)(c) (fiev. 5 -97) ` <br />Part 1 - Kepc By Recording Ofrke CAT. NO 60025X <br />