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<br />05/12/2009 XUE 14:17 FAX 402 471 4429 UCC SECRETARY OF SXAXE ~~~ Hall ~003/006 <br />, 200903649 <br /> <br /> <br />8801 <br /> <br />Form 668 (Y)(C) <br />(Rev. February 2004) <br /> <br />Department of the Treasury ~ Internal Revenue Service <br /> <br />Notice of Federal Tax Lien <br /> <br />Area: Serial Number <br />SMALL BUSINESS/SELF EMPLOYED AREA #4 <br />Lien Unit Phone: (800) 913-6050 542794109 <br /> <br />As provided by section 632., 6322, and 6323 of the Internal Revenue <br />Code, we are Jiving a notice that taxa (includinr 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 beionaing to this taxpayer for the amount of these taxes, and <br />additional penalties, interest, and costs that may accrue. <br /> <br />Name of Taxpayer TIMOTHY R CHAGNON <br /> <br />For Optional Use by Recordin Office <br /> <br /> <br />'TL <br /> <br />9909596364-4 P9S; 1 <br />CHAGNON TIMOTHY R <br />Fiied: 05/12/2009 01:06 PM <br /> <br />Residence <br /> <br />1505 E 7TH ST <br />GRAND ISLANDr NE 68801-2923 <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-5314 <br /> <br />Date of <br />Assessment <br />(d) <br />11/17/2008 <br /> <br />Last Day for <br />Refillng <br />(e) <br />12/17/2018 <br /> <br />Unpaid Balance <br />of Assessment <br />( <br />78616.04 <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 />78616.04 <br /> <br />This notice was prepared and signed at <br /> <br />CHICAGO, IL <br /> <br />, on this, <br /> <br />the <br /> <br />Olst day of May <br /> <br />2009 <br /> <br />Signature <br /> <br /> <br />Title <br />REVENUE OFFICER <br />(308) 384-4850 <br /> <br />24-10-1739 <br /> <br />for KAY PONTE <br /> <br />(NOTE: Certificate ot officer authorized by law to take acknowledgment is not essential to the validity of Notice of Federal Tax lien '\',J <br />Rev. Rul. 71.466, 1971 .2 C.B. 409) Form 668(Y)(c) (Rev. 2.2004) <br />Pan I - KepI By RecordlngOffice CAT. NO 60025X <br />