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02/25/2005 17:08 FAX 14024714429 NEBRASKA UCC <br />200501631 <br />9303 <br />Department of the Treasury - Internal Revenue Service <br />Form 668 (Y)(c) <br />(Rev. February 2004) 1 Notice of Federal Tax Lien <br />Q005/005 <br />Area: <br />Serial Number <br />For Optional Use by Recording Office <br />SMALL BUSINESS /SELF EMPLOYED AREA #9 <br />Lien Unit Phone: (651) 312 -8080 <br />207042504 <br />HE see of skate - ucc Fri <br />As provided by section 6321 ' 6322, 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 />39053 1177-9 Pips: 1 <br />property belonging to this taxpayer for the amount of these taxes, and <br />FMlid: R02/�52005 02:56 PM <br />additional penalties, interest, and costs that may accrue. <br />Name of Taxpayer R JAMES SMITH <br />Residence 1823 W 3RD STREET <br />GRAND ISLAND, NE 68803 -5421 <br />IMPORTANT RELEASE INFORMATION: For each assessment listed below, <br />unless notice of the lien is refiied 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 />Tax Period <br />Date of <br />Last Day for <br />Unpaid Balance <br />Kind of Tax <br />Ending <br />Identifying Number <br />Assessment <br />Refiling <br />of Assessment <br />a) <br />(b) <br />(c) <br />(d) <br />(e) <br />(f) <br />1040 <br />12/31/2002. <br />505 -70 -9724 <br />05/26/2003 <br />06/25/2013 <br />5041.91 <br />1040 <br />12/31/2003 <br />505 -70 -9724 <br />05/24/2004 <br />06/23/2014 <br />2023.24 <br />Place of Filing <br />Register of Deeds <br />Hall POBOX 1692 Total <br />$ 7065.15 <br />Grand Island, NE 68802 -1692 <br />This notice was prepared and signed at ST PAUL, MN , on this, <br />r. <br />fr <br />the 28th da of December 2004`•. <br />y i C.} <br />Signature Title <br />ACS 29 -00 -0008 <br />for S KILPATRICK (800) 829 -3903 <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. Rul. 71-466,1971 - 2 C.B. 409) Form 668(Y)(c) (Rev. 2 -2004) <br />a -- 4 - V— It- R— ArAinv offire PAT nin ann ,)Fx <br />