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08/16/2012 THU 14:48 FAX 402 471 4429 �CC SECRETARY OF STATE ��� Hall <br />;` <br />� <br />201206��.� <br />�003/003 <br />- "� N'I <br />�•. <br />�Ie6Fasli�-Department af <br />�E.��(�,� NOTICE �F STATE TAX LIEN <br />wvwir. r�evenue. r�e,go.v <br />This Notice of State Tax Llen Is issued by the Nebraska Department of <br />Revenue for unpaid taxes pursuant to the revenue laws of the state of <br />Nebraska. Notice Es hereby given that taxes including penal�es and <br />irrte�est, which a�e shown below, are due from the taxpayer specified <br />befow a�d remain unpaid after demand. These tax� cons�tute a lien <br />in the county fo� real and personai property I�longing to the ta�cpayer <br />or hereafter ac uired. <br />N�r�ska ldenti8cahon Number Federal Identiflcaton Num6er <br />97956716 <br />Li� Serial Number Lien Filed With Soaa! Seauity Number Spo+ue's Soct 3 <br />� 11293546 �Reglster ot Deeds QCamry Clerk XXX <br />Qate of Li� Li� Type ty <br />� 08/15/Z092 �Origin� QCord[nua8cn QCarrect�d HqLL <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAbdE IWD MAILING ADDRESS <br />' - CARLOS BERMUDEZ <br />I 122 N GRACE AVENUE <br />I GRAND ISLANfD NE 68803 <br />Category Tau Period Date of Amourn of Tax Penalty <br />Numbsr Assessment <br />22 2008 �1/Q6/2010 209.00 89.7b <br />Interest 1 AddiUons <br />42.95 <br />Balence of <br />Assessment Due <br />341.7Q <br />i I � I I TOTAL I$ 341.�o I <br />1 h�eby caUty that the Nebraska Department ' Revenue compfied wlth fhe revenue laws of the State of Nebraska in the detertmr�tlon of the <br />amount shorim to be due, arM Ute taxpayer has failed t� pay tt� amount due aftea demand. If this Notioe of State Tax Lien is an extension cf an <br />ef(p,ctive '., it ser�e.s b oonbm riority � the state's ir�teerest in the aifec�ed propeRy af the er. <br />� d �{ 9 Revenue Age�t g�jr aQ ' (402�71-6043 <br />sign re s nahae Title Date el�eNumb� <br />here ► r Revenue Supervisor �. /,f i�� <br />Signa ure TiUe Date <br />4-491-1B14 Reu 2•Z002 Super�Ees 4484-1974 R6v.1C-7895 <br />� <br />, <br />