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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 below, 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 Nebraska Identification Number 41813421 Federal Identification Number Lien Serial Number 11318052 Lien Fled With County Clerk Social Security Number XXX - XX - 4264 Spouse's Social Security Number g Register of Deeds I Date of Lien 02/12/2013 Lien Type zi Original II Continuation OCorrected County HALL BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS BRANDON J GROSSART 2004 E 7TH GRAND ISLAND NE 68801 Tax Category Number Tax Period Date of Assessment Amount of Tax Penalty - Interest - Additions - Balance of Assessment Due 22 2010 05/25/2011 455.00 32.75 49.42 537.17 TOTAL $ 537.17 I hereby certify that the Nebraska Department o` amount shown to be due. ard.the taxoaver has failed Revenue has complied with the revenue laws of the State of Nebraska in the determination of the to nav the arms int due after demand If this Nntire of State Tay I ion is an axtennnsion of an 02/13/2013 WED 15:11 FAX 402 471 4429 UCC SECRETARY OF STATE ffective sign here ■ rized Signature 201301240 Nebraska Department of REVENUE NOTICE OF STATE TAX LIEN www.revenue.ne.eov .state's interest in the affected property of the taxp Revenue Agent e evenue Supervisor Title Hall 2003 /003 NE Sec of Stake John R Gale - UGC ST 9913708655 -6 Pas: 1 GROSSART BRANDON J Filed: 02/13/2013 10:39 AM (402)471 -5731 Telephone Number Z/ s, /3 Date 4.494 -1974 Rev. 2 -2002 Supersedes 4.4941974 Rev. 10-1995