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<br />05/15/2009 FRI 14:34 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />~006/006 <br /> <br />Q) <br /> <br />\J Form 668 (Y)(c) <br />IRev. February 20041 <br /> <br />8801 <br /> <br />Department of the Treasury - Internal Revenue Service <br />~...... Notice of Federal Tax Lien <br /> <br />Area: Serial Number For Optional Uae by Recordin Office <br />SMALL BUSINESS/SELF EMPLOYED AREA #4 <br />Lien Unit Phone: (800) 913-6050 543942809 <br /> <br />A5 provided by section 6321, 6322, and 6323 of the Internal Revenue <br />Code, we are Biving a notice that taxes (Including interest and penalties) <br />have been assessed against che 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 />properey belonging to this taxpayer for the amount of these taxes, and <br />addidonal penalties, Interest, and costs that may accrue. <br /> <br />Name of Taxpayer CLUB 69 INC , a Corporation <br /> <br /> <br />200903784 <br /> <br />Residence <br /> <br />106 E 3RD ST <br />GRANDISLAND, NE 68801-5910 <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 rele8s8 8S defined <br />in IRe 6325(8). <br /> <br />kind of Tax <br />(a <br />941 <br />941 <br /> <br />Tax Period <br />Ending <br />(b) <br />09/30/2006 <br />12/31/2006 <br /> <br />Identifyina Number <br />(c) <br />20-3658058 <br />20-3658058 <br /> <br />Date of <br />Assessment <br />(d) <br />04/06/2009 <br />04/06/2009 <br /> <br />Last Day for <br />Refiling <br />(e> <br />05/06/2019 <br />05/06/2019 <br /> <br />Unpaid Balance <br />of Assessment <br />(f) <br />817.33 <br />346.84 <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 />1164.17 <br /> <br />This notice was prepared and signed at <br /> <br />CHICAGO, IL <br /> <br />, on this, <br /> <br />05th day of May <br /> <br />2009 <br /> <br />the <br /> <br />Signature <br /> <br /> <br />Title <br />REVENUE OFFICER <br />(402) 437-5462 x2912 <br /> <br />24-10-1720 <br /> <br />for DANIELLE L MUELLER <br /> <br />(NOTE: Certificate of ollicer authorized by law to take acknowledgment is not essential to the validity of Notice of Federal Tax lien <br /> <br />Rev. Aul. 71-466. 1971 - 2 C.B. 4091 Form 668(Y)(c) (Rev. 2-200410 <br />Part I - Kept By RKordinr OffIce CAT. NO 60025X \ <br />