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06/24/2005 08:33 FAX 14024714429 NEBRASKA UCC IM003/004 <br />01� - 200505738 <br />1872 <br />Department of the Treasury - Internal Revenue Service <br />(Rev. February 2004) <br />Form 668 (Y)(c) Notice of Federal Tax Lien <br />Area: Serial Number <br />SMALL BUSINESS /SELF EMPLOYED AREA 09 <br />Lien Unit Phone: (80(j) 93.3 -6050 232556205 <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 or these taxes, and <br />additional penalties, interest, and costs that may accrue. <br />Name of Taxpayer JAMES A MATSON <br />Residence 3090 W 2ND ST <br />GRAND ISLAND, NE 68803 -5264 <br />For Optional Use by Rerordina Office <br />IMPORTANT RELEASE INFORMATION! For each assessment listed below, <br />unless notice of the lien is refiied 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 />Kind of Tax <br />Tax Period <br />Ending <br />Identifying Number <br />Date of <br />Assessment <br />Last Da for <br />Refiling <br />(a <br />(b) <br />(c) <br />d) <br />(e) <br />941 <br />06/30/2004 <br />81- 0640267 <br />03/21/2005 <br />04/20/2015 <br />941 <br />09/30/2004 <br />81- 0640267 <br />03/21/2005 <br />04/20/2015 <br />941 <br />12/31/2004 <br />81- 0640267 <br />03/21/2005 <br />04/20/2015 <br />Place of Filing <br />Register of Deeds <br />Hall POHOX 1692 <br />Grand Island, NE 68802 -1692 <br />This notice was prepared and signed at <br />the 13th day of `Tune <br />2005 <br />ST PAUL, MN <br />NR frs .f i {.h - Me FT4 <br />9905 #60626 -7 Pas: 1 <br />MATSON JAMES p <br />Filed: 08/23/2005 03:31 PM <br />Unpaid Balance <br />of Assessment <br />8049.62 <br />7297.39 <br />5973.27 <br />Total 1$ 21320.28 <br />, on this, <br />Signature Title <br />REVENUE OFFICER 29 -10 -2341 <br />for PAT KELLOGG (308) 384 -6662 <br />(NOTE; Certificate of officer authorized by law to take acknowledgment is not essential to the validlty of Notice of Federal Tex lien <br />Rev.! Rul. 71 -466, 11971 - 2 C.B. 409) Form 668(17(c) (Rev. 2 -2004) �(t <br />Part 1 - Kept By Recording 010ce rn,r nin Rnn ?Fx 1 <br />