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Tax <br />Category <br />Tax Period <br />Date of <br />Amount of Tax <br />Penalty <br />Interest <br />Additions <br />Balance of <br />Number <br />Assessment <br />Assessment Due <br />05/02/2013 THU 15:21 FAX 402 471 4429 UCC SECRETARY OF STATE <br />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 />Nebraska Identification Number <br />8239665 <br />Lien Serial Number <br />/%3J (V / <br />Date of Lien <br />Business Name <br />Street Address <br />City <br />21 <br />21 <br />sign <br />here <br />04/25/2013 <br />Prep rer's Sig ature <br />, ut onzed Signature <br />Lien Filed With <br />BUSINESS NAME AND LOCATION ADDRESS <br />01/01/2012 09/25/2012 <br />06/30/2012 <br />201303515 <br />REVENUE NOTICE OF STATE TAX LIEN <br />YVYVVW.Mf V* es Vf r•O. V4 <br />Register of Deeds DCounty Clerk <br />Lien Type <br />State Zip Code <br />Original DContinuation [] Corrected <br />1,485.03 <br />Title <br />Federal Identification Number <br />Name <br />Revenue Agent <br />269.64 <br />39- 1964386 <br />PLEASE DO NOT WRITE IN THIS SPACE <br />Social Security Number <br />Hall <br />County <br />Hall <br />Street or Other Mailing Address <br />710 N. Diers Ave. Suite L. <br />City <br />Grand Island <br />55.34 <br />11111 11111111 <br />9913714239 -2 P9s: 1 <br />Filed:I�p021201300 AND <br />1 <br />TAXPAYER NAME AND MAILING ADDRESS <br />Grand Island Liquor Mart and Tobacco Row LLC <br />07/01/2012 <br />09/30/2012 <br />11/09/2012 <br />0.00 <br />13.03 <br />0.04 <br />TOTAL <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 shown to be du • he taxpayer has failed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of an <br />effective lien. it se . • ntinue the priori e state's interest in the affected property of the taxpaye <br />D te <br />Spouse's Social Security Number <br />State <br />Ne. <br />Zip Code <br />68803 <br />1,810.01 <br />13.07 <br />$ 1,823.08 <br />Telephone Number <br />Revenue Senior Agent 1-30-3 <br />Title Date <br />4- 494 -1974 Rev. 2.2002 Supersedes 4.494 -1974 Rev. 10-1995 <br />0003/003 <br />402 471 -6067 <br />• <br />