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08/09/ZO11 TUE 15:06 <br />u <br />Form b68 (Y)(t) <br />(Rev. February 20Q4) <br />FAx 402 471 4429 UCC SLCRETARY OF STATE ��y Hall <br />Area: Serial Number <br />SMALL BUSINESS/SEI;F EMPLOYED AREA #4 <br />Lien Unit Phone: (800) 913-6050 804925411 <br />As provided by section 6321, 6322, and 6323 of t6e Internal Revenae <br />Code, we are giving a notice t6at ta�ces (inctuding itnterest aad penattfes) <br />have been assessed against the foltovuing-aamed taxpayer. We haae made <br />a demaed for paym�nt of this liabiiity, but �t eeraains unpaid. Therefore, <br />there is a tien in favor of the [lnited States on �aU property and rights to � <br />property be[onging to th�s taxpayer for the amount of these taxes, and <br />addQtiona! penalties, interest, and costs that may actrue. <br />axpayer <br />Residence p0 BOX 15 Q� <br />DONIPHAN, NE 68832-015Q <br />2011a�92� <br />Department of the Treasury - lnternal Revenue Service <br />Notice of Federal Tax Lien <br />IMPORTANT RELFASE INFORMATION: For each assessment listed below, <br />u�less notics of the lien is refiled by the date Biven in column (e), thls notice shall; <br />on the day following such date, operats as a csrtificate of releese as dafined <br />in IRC 6325(a). � � � <br />� Tax Per�od Date of l.ast D�a�yfdr <br />Kind of Ta�c Ending Identifying Num6er Assessmeet Refrlin8 <br />1040 12/31/2007 XXX-XX-1025 11i02/2009 12/02/2019 <br />1040 12/31/2008 XXX-XX-1025 11/23/2009 12/23/2019 <br />Place of Filing <br />Register of Deeds <br />Ha.11 POBOX 1692 <br />Grand Island, NE 68802-1692 <br />�003/005 <br />Unpaid Balance <br />of Assessment <br />1180.01 <br />16681:04 <br />Total �$ 17861.05 <br />This notice was prepared and signed at <br />the 02nd day of August <br />CHICAGO, IL <br />2011 <br />, on this, <br />Signature � � Title <br />REVENUE �FFICER 24,-10-1720 <br />for DANIELLE L MUELLE (402) 473-4675 x2912 <br />�NdTE: Certificate of officer authorized by law to teke acknowledgment is not essential to the validity of Notice of Federal Tax Ifen � <br />Rev. Rul. 71-466, 1977 - 2 C.B. 409) Form 668(n(c) lRev. 2-20Q41 � j�� <br />� Part 1' KeP� 8�r Retord�n8 �� � CAT. NO 60025X Vv <br />For Opt{onal Uae by Recordfng Office <br />NH See aF Steie .7ahn A Gala - UCC FTL <br />9911668761-8 Pse: t <br />SHORT DEIdAYNE <br />Filed; 08/09J2011 �9:60 AM <br />, <br />