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This Notice of State Tax Lien is issued by the Nebraska Revenue for unpaid taxes pursuant to the revenue laws Nebraska. Notice is hereby given that taxes including penalties interest, which are shown bolo*, are due from the taxpayer below and remain unpaid after demand. These taxes constitute in the county for real and personal property belonging or hereafter acquired. Department of of the state of and specified a lien to the taxpayer PLEASE DO NOT WRITE IN THIS SPACE I PLEASE RETURN TO: NEBRASKA DEPT OF REVENUE PO BOX 94609 • LINCOLN NE 68509-4609 Nebraska Identification Number 46940596 - Federal Identification Number Lien Serial Number 11316345 Lien Filed With County Clerk Social Security Number XXX - 0386. Spouse's Social Security Number XXX - XX - 0452 3 Register of Deeds 1 Date of Lien 01/30/2013 Lien Type County HALL 7 Original 1 Continuation 1 Corrected BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS ANTONIO SIMAJ VICENTE ISABEL AJETAS AVILA 302 E 5TH ST GRAND ISLAND NE 68801 Tax Category Number Tax Period Date of Assessment Amount of Tax Penalty Interest Additions Balance of Assessment Due 22 2008 12/12/2011 505.00 126.25 95.05 726.30 TOTAL $ . 726.30 I hereby certify that the ijliebras)q Qepartm of Revenue has complied with the revenue laws of the State of Nebraska in the determination of the 02/05/2013 TUE 14:52 FAX 402 471 4429 UCC SECRETARY OF STATE amount shown to be effective lien, it sery • sign here • Aut zed SIM' Nebraska Department of REVENUE NOTICE OF STATE TAX LIEN www.revenue.ne.gov as failed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of an of he s - e's interest in the affected property of the taxpayer. Revenue Agent Title 201300959 Hall 01003 /005 NE sec of state J e UCC sTL Pas 1 59 13 V60EN ANTONIO Filed: 02105/2013 12:14 PM (308)632 -1210 Date Telephone Number Revenue Supervisor ! - —1 .1 Title Date 4. 494 -1974 Rev. 2 -2002 Supersedes 4- 494.1974 Rev. 10-1995