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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 />05/23/2013 THU 15:37 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 />10290958 <br />Lien Serial Number <br />Date of Lien <br />Business Name <br />Street Address <br />City <br />/13-3 i, c &' <br />0 1 <br />01 <br />01 <br />01 <br />01 <br />01 <br />sign <br />here <br />04/30/2013 <br />10/30/2011 02/02/2012 <br />Lien Filed With <br />BUSINESS NAME AND LOCATION ADDRESS <br />state Zip Code <br />11/01/2011 <br />01/25/2012 <br />11/30/2011 <br />12/01/2011 <br />12/31/2011 <br />01/01/2012 <br />02/29/2012 <br />03/01/2012 <br />03/31/2012 <br />04/01/2012 <br />04/30/2012 <br />02/02/2012 <br />05/01/2012 <br />05/22/2012 <br />06/01/2012 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />62.11 <br />66.28 <br />36.45 <br />25.00 <br />23.08 <br />26.08 <br />2.60 <br />14.17 <br />0.00 <br />160.00 <br />20.00 <br />0.22 <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 due, and 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 serves continue the priori the state's interest in the affected property of the taxpayer. <br />..� , ii <br />Prepa er's Signature <br />uthorized Signature <br />201304122 <br />Ns.brasko x7epurtmd.iH <br />REVENUE E NOTICE OF STATE TAX LIEN <br />wwrwr 0w <br />Register of Deeds DCounty Clerk <br />Lien Type <br />Original Continuation DCorrected <br />0.00 <br />Revenue Agent <br />Title <br />Federal Identification Number <br />Name <br />Street or Other Mailing Address <br />412 SUEZ ST. <br />City <br />CAIRO <br />177.22 <br />Revenue Senior Agent <br />Title <br />PLEASE DO NOT WRITE IN THIS SPACE <br />Social Security Number <br />XXX -XX -3049 <br />County <br />Hall <br />TAXPAYER NAME AND MAILING ADDRESS <br />VERNE O. HICKOK <br />65.39 <br />Hall 1003/011 <br />(..5 <br />N HGale - <br />Pg s: 1 S- <br />UCC <br />Filed: 05/23/2013 02:39 PM <br />Spouse's Social Security Number <br />State <br />NE. <br />Date <br />4 -494 -1974 Rev. 2.2002 Supersedes 4 -494 -1974 Rev. 10.1995 <br />Zip Code <br />68824 <br />242.61 <br />23.08 <br />248.19 <br />68.88 <br />70.62 <br />25.22 <br />$ 678.60 <br />402 471 -6067 <br />Telephone Number <br />