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May.24. 2018 3:5 F''M NE Secretary of State — UCC Form 668 (Y)(c) (Rev. February 2004) 11874 Area: SMALL BUSINESS /SELF EMPLOYED AREA #6 Lien Unit Phone: (800) 913 As provided by section 6321, 6322, and 6323 of the Internal Revenue Code, we are giving a notice that taxes (including interest and penalties) have been assessed against the following - named taxpayer. We have made a demand for payment of this liability, but it remains unpaid. Therefore, there is a lien in favor of the United States on all property and rights to property belonging to this taxpayer for the amount of these taxes, and additional penalties, interest, and costs that may accrue. Name of Taxpayer TORY M SEMM Residence IMPORTANT RELEASE INFORMATION: For each assessment listed below, unless notice of the lien is refiled by the date given In column (e), this notice shall, on the day following such date, operate as a certificate of release as defined in IRC 8325(a). Kind of Tax (a). 1040 1040 Place of Filing Signature for COLS 4174 ARIZONA AVE GRAND ISLAND, NE 68803 -1110' Tax Period Ending (b) 12/31/2010 12/31/2013 the 03rd day of May CHWAN Department of the Treasury - Internal Revenue Service Notice of Federal Tax Lien Identifying Number (c) XXX -XX - 8 9 6 1 XXX -XX - 8 9 6 1 Serial Number Date of Assessment (d) 03/12/2018 03/12/2 Register of Deeds Hall POBOX 1692 Grand Island, NE 68802 -1692 2018 Yr �.... d v__. 307173918 Last Day For Refilmg (e) 04 04/11/2028. Title REVENUE OFFICER (402) 473 -4671 J 46 0 3..2 For Optional Use by Recording Office NE S.c of Si.ie John a Gob. - UCC 11 F ?L 9 918812359 -5 PDs: 1 SEMI') TORY PI Filed! 05/24/2019 11x01 AM Total $ Unpaid Balance of Assessment (f) 7887.92 482.16 8370.08 This notice was prepared and signed at CHICAGO, IL , on this, 26-15-2722 (NOTE: Certificate of officer authorized by law to take acknowledgment is not essential to the validity of Notice of Federal Tax lien Rev. Rul, 71 -466, 1971 - 2 C.B, 409) Form 666(Y)(c) (Rev. 2 -2004)