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07/12/2005 16:49 FAX 14024714429 NEBRASKA UCC <br />IM 004/006 <br />1872 _ <br />Department of the Treasury - Internal Revenue Service aoo5�63'75 <br />Form 668 (Y)(c) Notice of Federal Tax Lien <br />(Rev. February 2004) <br />Area: Serial Number For Optional Use by Recording Office <br />SMALL BUSINESS/SELF EMPLOYED AREA #9 <br />Lien Unit Phone: (800) 913--6050' 235663505 ME a-G er st -4. - uee rL <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, 111111111111 Hill 1111111 ffill 1111111111111111 1111111 <br />there is a lien in favor of the United States on all property and rights to 8909402951 -8 Pus: 1 <br />property belonging to this taxpayer for the amount of these taxes, and Fiilled: 07/12/2005 12:42 PM ) <br />additional penalties, interest, and costs that inay accrue. <br />Name of Taxpayer JAMIE HAGAN <br />Residence 926 E CHESTNUT ST <br />CLARINDA, IA 51632 -1939 <br />IMPORTANT RELEASE INFORMATION: For each assessment listed below, <br />unless notice of the lien 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 IRC 6325(a). <br />Tax Period Date of last Day for Unpaid Balance <br />Kind of Tax Ending, Identifying Number Assessment Refiling of Assessment <br />(a (b ) (c d e (f) <br />940 12/31/2004 41- 2140120 05/09/2005 06/08/2015 3971.52 <br />941 06/30/2004 41- 2140120 05/02/2005 06/01/2015 8721.71 <br />9,41 09/30/2004 41- 2140120 05/02/2005 06/01/2015 15850.39 <br />941 12/31/2004 41- 2140120 05/02/2005 06/01/2015 16816.47 <br />Place •of Filing <br />Register of Deeds <br />Hall POBOX 1692 Total $ 45360-09 <br />Grand Island, NE 68802 -1692 <br />This notice was prepared and signed at ST PAUL, MN , on this, <br />the <br />30th day of June 2005 <br />Signature Title <br />REVENUE OFFICER 29- 011430 <br />for JIM DAUGHERTY (402) 361 -0357 <br />(NOTE: Certificate of officer authorized by law to take acknowledgment is not essential to the validity of Notice of Federal Tax lien <br />liiev. Rul. 71 -466, 1971 - 2 C.B. 409) Form 668(Y)(c) (Rev. 2 -2000.) <br />A__ . D -Alan r1mrn rAT nin annex <br />