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Tax . <br />- <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 />05/23/2013 THU 15:36 FAX 402 471 4429 UCC SECRETARY OF STATE <br />NF See of asa.. + - - -- <br />9913715758-3 Pes: 1 <br />HICKOK VERNE 0. <br />FUed: 05123/2013 02:39 PM <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 />10290958 <br />Lien Serial Number <br />I1�33 /S - 4 <br />Date of Lien <br />04/30/2013 <br />Business Name <br />Street Address <br />City <br />01 <br />01 <br />01 <br />01 <br />BUSINESS NAME AND LOCATION ADDRESS <br />05/31/2012 07/02/2012 <br />sign Preparer's Signature <br />Lien Filed With <br />Lien Type <br />201304121. <br />NOlanaaka 0eytxetrnent od <br />REVENUE UE NOTICE OF STATE TAX LIEN <br />wvvwr.rOW*Ps.r fr. ro *. v,rr.r <br />Register of Deeds 0County Clerk <br />State Zip Code <br />0.00 <br />Revenue Agent <br />�yy <br />Federal Identification Number <br />Original OContinuation Corrected <br />Name <br />VERNE 0. HICKOK <br />Street or Other Mailing Address <br />412 SUEZ ST. <br />City <br />CAIRO <br />25.00 <br />Social Security Number <br />XXX -XX -3049 <br />0.41 <br />Hall 11002 /011 <br />PLEASE DO NOT WRITE IN THIS SPACE <br />County <br />Hall <br />c/l /Ol <br />aaae <br />Spouse's Social Security Number <br />TAXPAYER NAME AND MAILING ADDRESS <br />State <br />NE. <br />Title . <br />here Al e.edA- Revenue Senior Agent <br />uthorized Signature Title Date <br />4 .494.1974 Rev. 2 -2002 Supersedes 4494 -1974 Rev. 10 -1995 <br />Zip Code <br />68824 <br />07/01/2012 <br />07/31/2012 <br />09/01/2012 <br />09/30/2012 <br />10/01/2012 <br />10/31/2012 <br />09/04/2012 <br />11/08/2012 <br />01/02/2013 <br />0.00 <br />163.87 <br />336.39 <br />0.00 <br />46.08 <br />33.64 <br />0.19 <br />7.53 <br />5.21 <br />TOTAL <br />100.00 <br />120.00 <br />300.00 <br />25.41 <br />100.19 <br />337.48 <br />675.24 <br />$ 1,138.32 <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 due, and he taxpayer has ailed to pay the amount due after demand. If his Notice of State Tax Lien is an extension of an <br />effective lien, it se o continue the prio of the state's interest in the affected property of he taxpayer. <br />402 471 -6067 <br />Telephone Number <br />5 =�i - 7j <br />