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04/22/2011 FRI 14:22 FAX 402 471 4429 UCC SLCRETARY OF STATE y-�-� ea11 <br />_�� <br />Forim 668 (Y)tc3 <br />(Rev. Ffltuuary 2004) <br />faloo2/ooz <br />Department of the Treasury - Internal Revenue Service <br />Notice of �ederal Tax Lien <br />Area: � Seriai Number - <br />SMALL $IISTNESS/SELF II�LOYED Al2F•A #4 <br />Lien Unit Phone: (800� 913-6050 775424411 <br />As provided by section 6321, 6322, and 6323 of the Int�rna! Revenue <br />Code, we are� g�ring a notice that taxes (incfuding incerest and penaldes) <br />have been assessed against the following�named taxpayer. We have made <br />a demand for payment of' this l�ability, but it rema�s unpaid. Ther�fore, <br />there is a lien in fauor of the tinited States ae alt property and �Ights to <br />property 6elong�ng to this taxpayer tor the amount a►f these taxes, and <br />additional penalties, interest, and. costs that may aurue. <br />Residence 4152 HARTFORD ST . <br />GRAND ISLAIJD, NE 68803-2255 <br />� 1MPORTANT RELEASE IN�ORMA'1�ON: For eaah assessment listed below, <br />unless notice of the lien is refiled by tHe date given in column (e!, this natice shall, <br />on the day fofiouving such date, operate as a certificate of release as defined <br />in 1RC 6325(a). <br />Kiad of Tax <br />1040 <br />Place of Filing <br />Tax Periad <br />Ending identf[ying Number <br />12/31/2005� XXX-XX-07S5 <br />201103099 <br />Date of <br />Asseument <br />(d) • <br />03/21./2011 <br />LasR Day f�or <br />eflin <br />04/20/2021 <br />; <br />. f <br />_._...�. <br />Unpaid Balance ; <br />of Assessment <br />(� ' <br />3640.25 � � <br />Register of Deeds <br />Hall POBOX 1692 <br />Grand Island, NE 68802-1692 <br />Total f $ 3640.25 ' <br />This notice was prepared and signed at CHICAGO, IL , on this, <br />the �2th day of April 2d11 <br />Signature � Title <br />REVENUE OFFICER 24-10-1720 <br />for DANIFLLE L MIIELL � �402� 473-4675 x2912 <br />(NOTE: Cart+ficate of ofncer authbrized by law to take acknowladgmant is not essential to the validity. of Notice of FedeFal Tax lian <br />Rev. Rui. 71 1971 - 2 C.B 4091 � Porm 668(ln(t) (Rev. 2-2004 <br />Part i- Kept By Recording Office CAT. NO 6�026X <br />Use <br />