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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 />PLEASE DO NOT WRITE IN THIS SPACE <br />Nebraska Identification Number <br />40338487 <br />Federal Identification Number <br />Lien Serial Number <br />1131 5996 <br />Llen Filed with <br />3 Register of Deeds II County Clerk <br />Social Security Number <br />XXX -XX -0762 <br />Spouse's Social Security Number <br />Date of Lien <br />01/29/2013 <br />Lien Type <br />g Original • Continuation • Corrected <br />County <br />HALL <br />BUSINESS NAME AND LOCATION ADDRESS <br />TAXPAYER NAME AND MAILING ADDRESS <br />OCTAVIO VENEGAS - RODRIGUEZ <br />1424 EAST 7TH ST <br />GRAND ISLAND NE 68801 <br />Tax <br />Category <br />Number <br />Tax Period <br />Date of <br />Assessment <br />Amount of Tax <br />Penalty <br />Interest <br />Additions <br />Balance of <br />Assessment Due <br />22 <br />2007 <br />11/07/2010 <br />4,274.30 <br />1,068.58 <br />1,109.21 <br />6,452.09 <br />22 <br />2009 <br />11/24/2010 <br />3,961.00 <br />198.05 <br />547.16 <br />4,706.21 <br />TOTAL <br />$ 11,158.30 <br />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 <br />amount o. be due,�� has fail pay the amount due after demand. If his Notice of State Tax lien is an extension of an <br />effective Wen. it selves to tl tv lnteraat in t affartrai nmrwrty of fha tavnav'r t <br />02/01/2013 FRI 12:30 FAX 402 471 4429 UCC SECRETARY OF STATE 0002/003 <br />0 � <br />sign <br />here • <br />Au <br />Signet <br />201 300858 <br />Nebraska.Departrnent of <br />RENUE NOTICE OF STATE TAX LIEN <br />WW W.revenue.:ne.gO v <br />Revenue Agent <br />Title <br />Revenue Supervisor <br />Title <br />NE Sec of Slake John A Gale - UCC ST <br />11 1 <br />I <br />9913707720 -4 Pgs: 1 <br />VENEGRS RODRI GUEZ OCTAVIO <br />Filed: 01/31/2013 09:48 AM <br />(402)471 -5731 <br />Telephone Number <br />/.. Z ?/ /' <br />Date <br />4-494-1974 Rev. 2-2002 Supersedes 4-494-1974 Rev. 10-1995 <br />