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<br />01/26/2006 13:42 FAX 14024714429 <br /> <br />NEBRASKA Dee <br /> <br />~ 010/011 <br /> <br />~~ ... <br /> <br />Form 668 (Y)(C) <br />(Rev. February 2004) <br /> <br />4102 <br /> <br />Department of the Treasury - Internal Re~enue Service <br />Notice of federal Tax Lien - <br /> <br />Area: <br />SMALL BUSINESS/SELF EMPLOYED AREA #1 <br />Lien Unit Phone: (BOO) 913-SQSO' 267975506 <br /> <br />A5 provided by section 6]21, 6322, and 6323 of the Internal Revenue <br />Code, we are giving a notice that iaxes (including interest and penalties). <br />have been assessed againsl 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 righU to <br />property belonging to this taxpayer for the amount of these taxes, and I <br />additional penalties, interestJ .and costs that may accrue. <br /> <br />Name of Taxpayer G DOUGLAS .CAMPLIN DDS PC. , .a Corporati n <br /> <br />Serial Number <br /> <br />For Optional Use by Recording Office <br /> <br />111"lll"'. ... <br /> <br />99064344 7~;~L IN ODS PC , fI C <br />G DOUdGL~S1/24/2006 04;32 PM <br />Fil. , Vol <br /> <br />Residence <br /> <br />2516 COTTONWOOD <br />GRAND ISLAND, NE 68801 <br />I <br /> <br />200600731 <br /> <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). I <br /> <br />. Kind of Tax <br />(a) <br />941 <br /> <br />Tax Period <br />Ending <br />(bl <br />12/31/2004 . <br /> <br />: Identifying Number <br />(c) <br />47-0752368 <br /> <br />Date of <br />A5sessment <br />(d) <br />12/05/2005 <br /> <br />Last Day for <br />~filing <br />! (e) <br />01/04/2016 <br /> <br />Unpaid Balance <br />of Assessment <br />(0 <br />8917.06 <br /> <br />Place of Filing <br /> <br />Regis.ter of Deeds <br />Hall POBOX 1692 <br />Grand !Island, NE 68802-1692 <br /> <br />Total $ <br /> <br />8917.06 <br /> <br />This notice was prepared and signed at <br /> <br />ST PAUL, MN <br /> <br />, on this, <br /> <br />the <br /> <br />12 th day of January <br /> <br />2006 <br /> <br />Signature <br /> <br />'.A4~' a fI'~ <br />for THERESA HARLEY <br />(NOTE: Certificate of officer al./thorized by law to take acknowledgment is not_essenti~1 to the validity of Notice of Federal Tax lien <br />Rev. Rul. 71-466.1971 - 2 C.~. 409) __ _ _ .. __ I Form 66B(Y)(c? (_R~v~~:~C:~~J <br /> <br /> <br />Title i <br />ACS I, <br />(800) 829-3903 <br /> <br />21-00-0008 <br /> <br />~ <br />