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Nebraska Identification Number 10145362 Federal Identification Number Social Security Number XXX -XX -3719 Spouse's Social Security Number Lien Serial Number 11155597 Lien filed with Date of Lien 04/04/2011 Tax Category 01 & 21 County Hall © Register of Deeds DCounty Clerk BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS Business Name Name Simon R. Jensen Street Address Street or Mailing Address 2720 St Patrick Ave. Apt. #1 City State Zip Code City State Zip Code Grand Island Ne. 68803 Type of Action 02/26/2013 TUE 12:13 FAX 402 471 4429 UCC SECRETARY OF STATE Pursuant to the revenue laws of the State of Nebraska, notice is hereby given the State Tax Lien which has been duly filed by the Nebraska Department of Revenue against the below -named taxpayer, is terminated, partially released, or subordinated to the extent indicated below. TERMINATION OF TAX LIEN. The State Tax Lien is hereby fully terminated. TAX PERIODS 0 PARTIAL RELEASE. TAX PERIODS 0 SUBORDINATION. sign. here Pre arer's Signature Authorized Signature 201301519 The State Tax Lien is subordinated as follows. Revenue Agent Title 2010 Title Senior Revenue Agent yyy Hall 0002 /007 NE See of State John R Gale - UCC 709 9913709379 -1 Pgs: 1 JENSEN SIMON R. Filed: 02/26/2013 10:41 PN t24, State Tax Lien Statement of Termination or REVENUE Certificate of Partial Release or www•.i aw. r wr.yav Subordination PLEASE DO NOT WRITE IN THIS SPACE UCC Instrument Number County Instrument Number The State Tax Lien is partially released as follows: UCC Instrument Number County Instrument Number UCC Instrument Number County Instrument Number 9911662109- 201193835 I hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in deter = tion of the termi n, partial release, or subordination indicated above. 402 471 -6067 Telephone Number Date 4 -232 -68 Rev. 8-96 Supersedes 4- 232-69 Rev. 10 -95