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06/02/2010 PTEp 14:15 FAX 402 471 4429 UCC 58CRETARY pF STATE ~~y Hall <br />Form 6 <br />68 (Y)(c) <br />(aev. February 2004- <br />.3592 <br />Department of the Treasury -Internal Revenue Service <br />Notice of Federal Tax Lien <br />~+rea: Serial Number <br />SMALL BUSINESS/SELF EMPLbYED AREA #4 <br />Lien Unit Phane: (8p0) 913-6050 659911510 <br />As provided by section 6321, 6322, and 6323 of the Internal Revenue <br />Cade, 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 Llnlted States on all property and rights to <br />property belonging to this taxpayer for the amount of these taxes, and <br />additional penalties, interest, and costs that may accrue. <br />Vame of Taxpayer JOHN G GROSS <br />Residence 3720 WEST STATE STREET. A7 <br />GRAND ISLAND, NE 68803-2355 <br />IMPQRTANT RBLEASIr 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 />an the day following such date, operate as a certificate of release as defined <br />in IRC 6325(x). <br />Tax Period Date of last Dayy for <br />Kind of Tax Bnding Identifying Number Assessment Refiling <br />a fib) c d) Le) <br />1040 12/31/2003 XXX-XX-1510 04/17/2006 05/17/2016 <br />1040 12/31/,2004 XXX-XX-1510 11/23/2009 12/23/2019 <br />1040 12/31/2005 XXX-XX-1510. 11/23/2009 7.2/23/20].9 <br />Place of Filing <br />X003/003 <br />• •^.......,iinC Ofl1Ce <br />2oioo381s <br />Unpaid Balance <br />of Assessment <br />298.72 <br />48].18.42 <br />8796.$5 <br />Register of Deeds <br />Hall POSOX 1692 <br />Grand 7:sland, NE 58802-1692 <br />Total ~ $ 57213.99 <br />This notice was prepared and signed at <br />the 25th day of May <br />Signature ~ A <br />for DANIELLE L MUELLER <br />on this, <br />Title <br />REVENUE DFFICER 24-10-1720 <br />(402) 473-4675 x2912 <br />2010 <br />CHICAGO, IL <br />.--_-..- „~...,......,. M. ~~.~..~. eu,nyn4CV 4ry inw w ~aKe acKnowieogment is not essenUai to the validity of Notice of Federal Tax lien <br />Rev. Rul. 77-466, 1977 - 2 C.B. 409) <br />Part 1 -Kept ey Recording Office Farm b68(Y)(c) (Rev. 2-2004) <br />CAT. NO 6p025X <br />OR05S JOHAj G a -- ., na,i <br />Filed: pgs` 1 <br />06/02/2010 01:37 PIS <br />