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06/02/2010 WEb 14:15 FAX 402 471 4429 UCC SECRETARY OF STATE ~yy Hall <br />IaJ002/003 <br />3592 <br />Department of the Treasury -Internal Revenue Service <br />Form 668 (Y)(c) <br />(Rev. February 2004) Notice of Federal Tax Lien <br />Area: Serial Number For Optional Use by Recvrdlnp Office <br />SMALL BU'SIIVESS/SELF EMPLOYED AREA. #4 <br />Lien Unit Phone: (800) 913-6050 659911310 <br />As provided by section 6321, 6322, and b323 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 />property belonging to this taxpayer for the amount of these taxes, and <br />additional penalties, interest, and caxts that may attrue. <br />Name of Taxpayer CLUB 59 INC, a Corporation <br />NE SsG of SiHe John R Goly - l1GC FTL <br />9910829890-6 p9s, ~ <br />F11edBg06N02f2010 p~R3~IPM <br />201003817 <br />Residence 106 E 3RD ST <br />GRANDTSLAND, NE 68801-5910 <br />IMPORTANT RELI;,ASE INFORMATIQN: Far 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 release as defined <br />in IRC 6325(x). <br />Tax Period Date of last Dayy for <br />Kind of Tax I"nding Identifying Number Assessment Refiling <br />a) b) (c) (d) e) <br />941 09/30/2008 20-3658058 08/24/2009 09/23/2019 <br /> <br />Place of Filing <br />7.685 .86 <br />Register of Deeds <br />Hall )?OBOX 7.692 <br />Grand Island, NE 68802-7.692 <br />Total ~$ 15'85.86 <br />This notice was prepared and signed at CHICAGO, IL <br />the 25th day of May 207.0 <br />on this, <br />Signature ~{ y ~~~~~ Title <br />'1 REVENUE OFFICER 24-10-1721 <br />for DANIELLE L MUELLER (402) 473-4675 x2912 <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) <br />Part 1 -Kept By Recording Office Form 668(Y)(c) (Rev. 2-20041 <br />• CAT. NO 60026X <br />Unpaid Balance <br />of Assessment <br />