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09/30/2009 WED 13:51 FAR 402 471 4429 UCC SECRETARY OF STATE y-~-~ Hdll <br />Form bb$ (Y)(c) <br />(Rev. February 20041 <br />5 ~ 91 __... <br />Department of the Treasury -Internal Revenue Service <br />Notice of Federal Tax Lien <br />.~- ..r slake Jvl+n A bale -UCC FTL <br />~ooz/ooz <br />Area: Serial Number For <br />SMALL BUSINESS/SELF EMPLOYED AREA #4 <br />Lien Unit Phone: (800) 913-6050 583587.309 <br />As provided by section b~21, b~22, and b3Y3 of the internal Revenue <br />Cade, we are giving a notice that taxes (including interest and penalties) ps:: ~ <br />9909608389-1 <br />have been assessed against the #ollowing-named taxpayer. We have made cuusearsoN Many E <br />Fllad: 09/30/2009 10:00 RM <br />a demand far 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 /> <br />additional penalties, interest, and Costs that may accrue. ~ O 0 9 ~ ~ 9 0 5 <br />Name of Taxpayer MARY E CULBERTSON <br />Residence 214 N 1~IADISON ST <br />GRAND ISLAND, NE 68801-5735 <br />IMPORTANT RELEASE INFORMATION: For each assessment listed below, <br />unless notice of the lien is refiled by the date given in column le), this notice shall, <br />on the day fallowing such date, operate as a certificate of release as defined <br />in IRC 6325(a). <br /> Tax Period Date of fast Dayy for Unpaid Balance <br />Kind of Tax Ending Identifying Number Assessment Refiling of Assessment <br />(a) b c) d (e) (f) <br />1040 12/31/2001 XXX-XX-4647 07/18/2005 08/17/2015 2624.00 <br />1040 12/31/2002 XXX-XX-4647 07/18/2005 08/17/2015 7.5249.40 <br />7.040 12/31/2003 XXX-XX-4647 03/30/2009 04/29/2019 9120.93 <br />Place of Filing <br />Register of Deeds <br />Ha11 POHOX 1692 Total $ <br />Grand Island, NE 68802-1692 <br />26994.33 <br />This notice was prepared and signed at CHICAGO, IL <br />the ___.21st day of September 2009 <br />an this, <br />Signature ~ A ,1 REVENiTE OFFICER 24-1p--1739 <br />for KAY PONTE (308) 384-4850 <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 b68(Y)(c) (Rev. 2-20041 <br />Part 1 -Kept ny 1Retprding Office CAT. NO fi0025X <br />