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T ax <br />- - - <br />- -- <br />. -_. <br />.,--- , <br />Category <br />• 'Number <br />.. <br />Tax Period <br />nernernnee <br />Date of <br />Assessment <br />Amount of Tax <br />Penalty <br />i <br />Interest <br />Additions <br />Balance of <br />Assessment Due <br />12/14/2012 FRI 15:26 FAX 402 471 4429 UCC SECRETARY OF STATE <br />This Notice of State Tax Lien is issued by the Nebraska Department of <br />'Revenue for unpaid taxes pursuant to the revenue laws of the state of <br />Nebraska. Notice is hereby given that taxes including penalties and <br />interest, which are shown below, are due from the taxpayer specified <br />below and remain unpaid after demand. These taxes constitute a lien <br />in the county for real and personal property belonging to the taxpayer <br />or hereafter acquired. <br />Nebraska Identification Number <br />10899286 <br />Lien Serial Number <br />Date of Lien <br />12/10/2012 <br />Business Name <br />;Street Address <br />City <br />21 <br />21 03/31 /2011 05/25/2011 <br />21 <br />sign e <br />BUSINESS NAME AND LOCATION ADDRESS <br />Signature <br />here <br />lEi <br />Lien Type <br />Authorized Signature Title <br />?:wFarerak� <br />DIPpiltelnr.vot o! <br />� E1V'EvNUE NOTICE OF STATE TAX LIEN <br />Lien Filed With <br />Register of Deeds DCounty Clerk <br />Federal Identification Number <br />Original EiContin uation Corrected <br />State Zip Code <br />0.00 <br />Name <br />201210673 <br />27- 4427823 <br />Social Security Number <br />XXX -XX -6539 <br />Corey Sheldon <br />County <br />Hall <br />Street or Other Mailing Address <br />518 E. 5th St. Apt. #3 <br />City <br />0.13 <br />0.01 <br />Hall <br />1 hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in th <br />.ernount shown to be due, and he taxpayer has ailed to pay the amount due after demand. If this Notice of State Tax Lien is <br />effective lien, it sere o continue the priorit f the state's interest in the affected property of the taxpayer. <br />Revenue Agent <br />Title Date <br />Senior Revenue Agent <br />NE Sac of State Jahn A Gale - UCC SIL <br />9912704627 -1 Pss: 1 <br />SHELDO1 COREY <br />Filed: 12/14/2012 10:32 AM <br />PLEASE DO NOT WRITE IN THIS SPACE <br />Spouse's Social Security Number <br />TAXPAYER NAME AND MAILING ADDRESS <br />State <br />04/01/2011 <br />06/30/2011 <br />07/01/2011 <br />09/30/2011 <br />03/05/2012 <br />03/05/2012 <br />121.88 <br />30.00 <br />7.76 <br />0.00 <br />25.00 0.00 <br />TOTAL <br />$ 184.78 <br />e determination of the <br />an extension of an <br />4.494 -1974 Rev. 2.2002 Supersedes 4 -494.1974 Rev. 10.1995 <br />Ia1005/009 <br />Zip Code <br />0.14 <br />159.64 <br />25.00 <br />402 471 -6067 <br />Telephone Number <br />//_ <br />Date <br />