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04/06/2012 FRI 15:22 FAX 402 471 4429 UCC SECRETARY OF STATE �-+-� Hall <br />♦ <br />� , <br />201202'741 <br />vvtir u7F1 <br />Filed: �4/06J2012 10:24 Alq <br />_ <br />tt�b.a��sis+o G►a�arbnssnt �a�I <br />���� <br />W �uWN.r �Yf roa�t�'. aa �.9 tlrv <br />NOTICE OF STATE TAX LIEN <br />This Notice of State Tax Lien is Issued by the Nebraska Department of <br />Revenue for unpaid taxes pursuant to the �avenua laws of the staEe of <br />Nebraska. Notice Ps hereby given that taxes Including penaltfes and <br />interest, which are shown below� are due from the taxpayer specified <br />below and remain unpaid after demand. These tanes constitute a lien <br />in the county for real and personal properly b�longing to the taxpayer <br />or hereafter acquired. <br />9027386 <br />QX Register of Deeds �County Clerk XXX-XX <br />ate of Lien Lien Type County <br />03/27/2012 [�X Original �Continuatien �Corrected Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />usiness Name Name <br />GOL.F USA SCOTT GALUSHA <br />treet Address Street or Other Mailing Address <br />1004 DIERS AVE. STE. 230 314 WAINWRIGHT <br />iry a e Zip Code city state zip code <br />GRAND ISLAND NE 68803 GRAND ISLAND NE 68801 <br />Tax <br />Category Tax Pertod Date of Amount of Tax Penalty Interest Additions Balance of <br />Number Assessment <br />11/01/2010 <br />01 OS/04/2011 0.00 .Q <br />11/30/2010 <br />01 01 /01 /2011 08/04/2011 <br />04/30/2011 <br />01 05/01 /2011 07/06/2011 <br />05/31 /2011 <br />06/01 /2011 <br />01 11 /30/2011 02102/2012 <br />0.00 <br />0.00 <br />5,499.97 <br />� <br />� � �� �� �� <br />� �� � �� �� �� <br />� ' .� - <br />- - <br />_ • . <br />�]003/003 <br />sessment Due <br />115.02 <br />488.46 <br />100.00 <br />6,154.14 <br />$ 6,857.62 <br />i nereoy wrury ma� �ne rveorasKa uepaRmen� or rcevenue nas compnea wrcn tne revenue iaws or tne state ot rveorasKa in [ne aeterminanon ot tne <br />amount shown to be due, and the taxpayer has failed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of an <br />effective lien, it se continue the priori the state's interest in the affected property of the ta�cpayer. <br />8 � � Revenue A�ent by6s' o/� 402 471-6067 <br />sign Preparer's Signature Title Date 7elephone um r <br />here e Senior Revenue Agent �.ar'- /Z. <br />ut o�zed Signa ure Title Date <br />4r184-1874 Rev. 2-2002 Supersatlea 4�q9q-1974 Rev.141895 <br />� <br />,'\ : <br />