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<br />02/24/2009 TUE 15:51 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />1210021004 <br /> <br />.- <br /> <br />:1\.",) <br />\J <br /> <br />8801 <br /> <br />Form 668 (Y)< c) <br />(Rev. February 20041 <br /> <br />Department of the Treasury ~ Internal Revenue Service <br />Notice of Federal Tax Lien <br /> <br />Area: Serial Number <br />SMALL BUSINESS/SELF EMPLOYED AREA #4 <br />Lien Unit Phone: (800) 829-3903 517652409 <br /> <br />As provided by section 6321, 6322, and 6]23 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 /> <br />Name of Taxpayer TERRY A DERBY <br /> <br />For Optional Use by Recording Office <br /> <br />Irlr~lJlrl'lnll <br /> <br />9909587989-7 Pgs: 1 <br />DERBY TERRY A <br />Filed: 02/24/2009 12:24 PM <br /> <br />200901385 <br /> <br />Residence <br /> <br />518 E CAPIT~ NUMBER 38 <br />GRAND ISLAND, NE 68801-2472 <br /> <br />. <br /> <br />,. <br /> <br />IMPORTANT RELEASE INFORMATION: For each assessment listed below. <br />unless notice of the lien is refiled by the date given in column (el. this notice shall. <br />on the day following such date. operate as a c~rtificate - of release as defined <br />in IRC 6325(al. <br /> <br />i. <br /> <br />Kind of Tax <br />(a) <br />1040 <br /> <br />Tax: Period <br />Ending <br />(b) <br />12/31/2005 <br /> <br />Iden'tlfYing Number <br />(c) <br />XXX-XX-0190 <br /> <br />Date of <br />Assessment <br />(d) <br />OS/29/2006 <br /> <br />Last Day for <br />Refiling <br />(e) <br />06/28/2016 <br /> <br />Unpaid Balance <br />of Assessment <br />(f) <br />2491.93 <br /> <br />Place of Filing <br /> <br />Register of Deeds <br />Hall POBOX 1692 <br />Grand Island,NE 68802-1692 <br /> <br />Total $ <br /> <br />2491. 93 <br /> <br />This notice was prepared and signed at <br /> <br />CHICAGO, IL <br /> <br />, on this, <br /> <br />the <br /> <br />13 th day of February <br /> <br />2009 <br /> <br />Signature <br /> <br /> <br />'" <br /> <br />for MICHAEL W. COX <br /> <br />Title <br />ACS <br />(800) 829-3903 <br /> <br />24-00-0008 <br />V <br /> <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. Ru!' 71-466.1971 - 2 C.B. 409) . <br /> <br />n...... 4 U__",".IlII... ft_..._..;~I-..i._ ...~~_ <br /> <br />Form 668(Y)(c) (Rev. 2.2004) <br />