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Area: <br />SMALL BUSXISS /SELF EMPLOYED AREA # <br />Lien Unit Phone: (800) 913 -6050 <br />Jul. 18, 2018 3:1i FM • NE Secretary o t State — UCC <br />Form 666 (Y)(c) <br />(Rev. February 2004) <br />Name of Taxpayer TORY M SEMM <br />Residence <br />1 <br />Kind of Tax <br />(a) <br />1040 <br />1040 <br />Place of Filing <br />the 10th day of July 2018 <br />Signature <br />for COLB <br />Tax Period <br />Ending <br />(b) <br />12/3 <br />12/31/2012 <br />SCHWAN <br />11874 <br />Identifying Number <br />(c) <br />XXX- XX- 8961 <br />XXX -XX -8961 <br />Department of the Treasury - Internal Revenue Service <br />Notice of Federal Tax Lien <br />Serial Number <br />4174 ARIZONA AVE <br />GRAND ISLAND, NE 68803 -1110 <br />Date of <br />Assessment <br />(d) <br />05/21/ <br />03/12/2018 <br />Register of Deeds <br />Hall POBOX 1692 <br />Grand Island, NE 68802 -1692 <br />315130016 <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 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 />IMPORTANT RELEASE INFORMATION: For each assessment listed below, <br />unless notice of the Ilen 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 1RC 6325(a)- <br />Last Day for <br />Reffling <br />(e) <br />06/20/2026 <br />04/11/2028 <br />Title <br />REVENUE OFFICER <br />(402) 473 -4671 <br />Nc, 4862 F. 3 <br />2018046 0 <br />For Optional Use by Recording Office <br />N2 see of seat* John A d. a UCC FiL <br />f <br />9918818051 -7 ' Pas: 1 <br />SEMM TORY M <br />Filed 07/1U/2019 11!33 RM <br />Total $ <br />Unpaid Balance <br />of Assessment <br />(0 <br />7389.96 <br />8955.44 <br />16345.40 <br />This notice was prepared and signed at _ CHICAGO, IL , on this, <br />26 -15 -2722 <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. Rul. 71-466, 1971 - 2 C.B. 409) _ - - Form 668(Y)(c) (Rev. 2 -2004) <br />