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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 in the county for real and personal property belonging to the taxpayer or hereafter ac • uired. PLEASE DO NOT WRITE IN THIS SPACE Nebraska Identification Number 99674149 Federal Identification umber Lien Serial Number 11318694 Lien Filed With Social Security Number Social Security Number 3 Register of Deeds II County Clerk XXX -XX -7312 'Spouses Date of Lien 02/15/2013 BUSINESS NAME AND LOCATION Lien Type ®Original 1 Continuation ADDRESS / Corrected TAXPAYER County HALL NAME AND MAILING ADDRESS DALE L KOKES 1015 N BROADWELL AVE GRAND ISLAND NE 68803 Tax Category Number Tax Period Date of Assessment Amount of Tax Penalty Interest Additions Balance of Assessment Due 22 2004 05/15/2011 433.00 108.25 202.16 743.41 TOTAL $ 743.41 I hereby certify amount stD effective li n, that the Neb due,; the it se es to tine ka Department o yer has th riority •. fii.; Revenue has complied with -led to pay the amount due state's interest in the affected the revenue laws after demand. If property of of the State of Nebraska in the determination of the this Notice of State Tax Lien is an extension of an the taxpayer. / 02/20/2013 WED 14:45 FAX 402 471 4429 UCC SECRETARY OF STATE -. -. Hall id 0002 /002 S I rl .j I �J.- �� J g .' - s i9 here • ture Authorized Signature 201301394 Nebraska Department of NE Sew of State J ^ ^^ - 9913708964 1 - P9 s: 1 KOKES DRLE L Filed: 02!20/2013 09:44 RM REVENUE NOTICE OF STATE TAX LIEN www.revenue.ne.gov Revenue Agent Title Revenue Supervisor Title (402)471 -5731 Telephone Number Date 4.494.1974 Rev. 2.2002 Supersedes 4- 494.1974 Rev. 10.1995