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10/27/2009 TUE 15:06 PAx 402 471 4429 UCC SECRETA1tY OF STATL y~y Hall Form bb8 (Y)(c) (ttev. February zoaa~ Department of the Treasury -Internal Revenue Service Notice o~ Federal Tax lien 2 D D 9 D 8 5'7 5 A Serial Number Far Optional Use by Recording Office rea: SMALL BUSINESS/SELF RNIPY,OYEII AR?SA #4 Lien Unit Phone: (800) 829-3903 589926509 of S~+kr John A 6.1e - UCC FTL NQ S As provided by section 6321, 6322, and 6323 of the internal Revenge ea Code, we are giving a notice that taxes (including interest and penalties) have been assessed against the following-named taxpayer. We have made a demand for payment of this liability, but it remains unpaid, Therefore, there is a lien in favor of the united States on all property and rights to P g ~ 1 property belonging to this taxpayer for the amoulnt of these taxes, and s 990981®578-2 FORSYTME RU55ELt_ 0 1R additional penalties, interest, and casts that may accrue. Fi lad: 10/27/2009 11:54 RM Name of Taxpayer RUSSELL O & LORI FORSYTHE JR Residence 407.4 BUCKINGHAM DR GRAND ISLAND, NF 68803-6401 IMPORTANT R~L~ASI~ INFORMATION: For each assessment listed below, unless notice of the lien is raffled by the date given in column (e), this notice shall, an the day following such date, operate as a certificate of release as defined in IRC 6325(a). Tax Period Date of Last Dayy for unpaid Balalnce Kind of Tax Ending Identifying Number Assessment Re filing of Assessment (a) (b) c d e) (~ 1040 12/31/2007 X•XX-XX-547.3 11/03/loos 12/03/2018 40167.61 Place of Piling X003/009 Register of Deeds Ha11 POBOX 1692 Grand Island, NE 68802-1692 Total ~ $ 4 016 7.61 This notice was prepared and signed at CHICAGO, IL the 14th day of October 2009 on this, Signature y ` for MICHAEL W. COX Title ACS (800) 829-3903 24-00-0008 V' (N07'E: Certificate of officer autharized by lew to take acknowledgment is not essential to the validity of Notice of Federal Tax lien ~ Rev. Rul. 71-466, 1971 - 2 C.B. 409) __ - - .. _M Farm bb8(Y)(r) IRev. 2-2004)