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10/26/2011 PiSD 13:40 <br />Form 668 (Y)(c) <br />(Rev. February 2004) <br />FAX 402 471 4429 UCC SBCRETARY OF 5TxTL yy-� Hall <br />Area: Serial Number <br />SMALL BUSINESS/SELF EMPLOYED AR.EA #4 <br />Lien Unit Phone: (800) 913-6050 821882011 <br />As provided by section 6321, 6322, and 63�23 of the Internal Revenue <br />Code, we are giving a notice that taxes (including interest and penalti�s) <br />have been assessed against t6e follawing-named taxpayer. We have made <br />a demand fitr �payment 9f this IiaMility, but it remains unpaid. Ti�erefore, <br />there is a liee in favor of the United States on ail property and rlghts to <br />property betonging to t6is ta�cpayer for the amount of th+ase taxes, and <br />additional penalties, interest, and costs that may aarue. <br />For Optional Use <br />Residence 2455 LAMAR AVE <br />GR.AN7� ISL�fND, NE 688Q3 <br />1MPORTANT ItELEASE INFORMATION For each assessme�t listed below, <br />unless notice af the.lien is refilad by the date giyen in column (e), this notice shall, <br />on the day following such' date, operate as a certifiicate of release as defined <br />in IRC 6325(a?. � <br />Taut Period Date of Last Day for <br />Kind of Tax Ending Identify.ing Nnmber Assessment Reflling <br />6672 09/30/2009 XXX-XX-0433 09/05/2011 10/05f2021 <br />6672 12/31/2009 XXX-XX-0433 09/05/2011 10i05/2021 <br />6672 03/31/2010 XXX-XX-Q433 09/QS/2Q11 10/05/2021 <br />6672 06/30/2010 XXX-XX-0433 09/05j2011 10/05/ZQ21 <br />6672 09/30/2010 XXX-XX-0433 09/05/2011 10/05/2021 <br />� �e:�e aM <br />Department of the Treasury - Internat Revenue Service � <br />Notice of Federal Tax Lien � o i l o� a i 9 <br />Place of Filing <br />Register of Deeds <br />Hall POBOX 1692 <br />Grand Island, NE 68802-1692 <br />Total � $ <br />This notice was prepared and signed at <br />the � 18 th �ay of October <br />CHICA.GO, IL <br />2011 <br />, on this, <br />Signature Title <br />��` REVENUE �FFICER 24-10-1.739 . <br />tor KAY PONTE (308) 384-4850' � � <br />(NOTE: Certificate of officer authorized by law to take acknowledgment fs not essential to the validity of Notice of Federal Tax lien . <br />Rev. Ru1. 77'-466,.1971 - 2 C.B. 4�9) • ' Form 668(n(t) (Rev..2-2004 <br />Part 1- Kept By Recording O(fice CAT. NO 60026X <br />�ooz�ooa <br />CG FTL <br />I <br />�: � <br />[Inpaid Batance <br />of Assessment <br />8563.75 <br />1.0794.72 <br />12217.31 <br />10321.. 65 <br />13238.61 <br />55136.04 <br />