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12/14/2012 FRI 15: 26 FAX 402 471 4429 UCC SECRETARY OF STATE -+-.. Hall 2007/009 NE Sec of Slake Jahn A Gale - UCC 5TL 1 I db . 1210675 9912704629-5 Pgs: 1 • SHELDON COREY Filed: 12/14/2012 10:44 AM 1l'Fbrrsks De .artr Prlt C1 REVENUE NOTICE OF STATE TAX LIEN wWw'..ar vQ n•..10..,b.q av . PLEASE DO NOT WRITE IN THIS SPACE This Notice of State Tax Lien is issued by the Nebraska Department of Revenue for unpaid taxes pursuant to the revenue laws of the state of Nebraska. Notice is hereby given that taxes including penalties and -interest,which are shown below, are due from the taxpayer specified below and remain unpaid after demand.These taxes constitute a lien I. in the county for real and personal property belonging to the taxpayer 'or hereafter acquired. 2 .Nebraska Identification Number Federal Identification Number 10899286 27-4427823 Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number '1 i a9 ipt / ©Register of Deeds County Clerk XXX-XX-6539 . Date of Lien Lien Type County 12/10/2012 ©Original OContinuation ation ❑Corrected Hall • BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS I Business Name Name • Corey Sheldon Street Address Street or Other Mailing Address 518 E. 5th St. Apt. #3 '-City State Zip Code City State Zip Code Grand Island Ne, 68801 Tax - Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of Number Assessment Assessment Due 05/01/2011 01 03/05/2012 265.00 73.00 26.05 364.05 1 05/31/2011 01 06/01/2011 03/05/2012 365.00 73.00 25.20 463.20 06/30/2011 • 01 07/01/2011 03/05/2012 365.00 73.00 23.65 461.65 07/31/2011 08/01/2011 01 03/05/2012 365.00 73.00 22.10 460.10 08/31/2011 ' ' 01 09/01/2011 03/05/2012 730.00 146.00 39.65 - 915.65 10/31/2011. i. TOTAL $ 2,664.65 • I hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in the determination of the 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 .`effective lien,it se to continue the priori,�:f the state's interest in the affected property of the taxpayer. 0 .- - , 4 �',y * Revenue Agent At/ 0 A� o/ 402 471-6067 sign -rep-rer's Signature Title Date Telephone Number here e , 4. 4 , / v _ �/I; Senior Revenue Agent /„2—/4.42-- .Ruth•"zed Sign- re Title Date . 4794-1974 Rev.2-2002 Supersedes 4-494-1974 Rev.10-1995 ■ • (4) I..