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<br />05/05/2009 TUE 14:13 PAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />lZIo 0 2/ 0 0 3 <br /> <br />OJ <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 Lie~ 200903469 <br /> <br />Area: Serial Number <br />SMALL BUSINESS/SELF EMPLOYED AREA #4 <br />Lien Unit Phone: (800) 829-3903 541131209 <br /> <br />As provided by section 6321, 6]22, 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 beloneing to this taxpayer for the amount of these taxes, and <br />additional penalties, interest, and costs that may accrue. <br /> <br />Name of Taxpayer TAMERA S JACOBSON <br /> <br />For Optional Use by Recording Office <br /> <br /> <br />9909595577-4 pgs: 1 <br />JRCOBSON' TRMERA S <br />Filed: 05/06/200901:25 PM <br /> <br />Residence <br /> <br />2323 BELLWOOD DR <br />GRAND ISLAND, NE 68801-8205 <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). <br /> <br />Kind of Tax <br />a) <br />1040 <br /> <br />Tax Period <br />Ending <br />(b) <br />12/31/2003 <br /> <br />Identifying Number <br />(c) <br />XXX-XX-9365 <br /> <br />Date of <br />Assessment <br />(d) <br />05/19/2008 <br /> <br />Last Day for <br />Refiling <br />(e) <br />06/18/2018 <br /> <br />Unpaid Balance <br />of Assessment <br />(f) <br />9603.83 <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 />9603.83 <br /> <br />This nOTice was prepared and signed at <br /> <br />CHICAGO, IL <br /> <br />__....__.."._.... ...._.__...._______________ ,on this, <br /> <br />the ~_~_~.~.~._ day of April <br /> <br />2009 <br /> <br />SignaTure <br /> <br /> <br />Title <br />ACS <br />(800) 829-3903 <br /> <br />24-00-0008 <br /> <br />for MICHAEL W. COX <br /> <br />(NOTE: Certificate ot otficer aulhorizecl by law to lake acknowledgmenl is not essenli", 10 lhe validity at Notice at Federal Tax lien .\ <br />Rev. Rul. 71-466,1971.2 C.B. 4091 Form 668(Y)(c) IRev. 2.200411\\'..} <br />Part I . Kept By Recording Office CA T. NO 60025X : l.) <br />