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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 15:37 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 />/ /33is (. 7 <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 />01 <br />01 <br />sign <br />here <br />Lien Type <br />BUSINESS NAME AND LOCATION ADDRESS <br />06/30/2010 09/07/2010 <br />State Zip Code <br />201304123 <br />P rbraekā–  tape: Iry #ni of <br />REVENUE E NOTICE OF STATE TAX LIEN <br />www.rrvrnur...r:.sov <br />Federal Identification Number <br />Lien Filed With Social Security Number <br />Register of Deeds (County Clerk XXX -XX -3049 <br />Original UContinuation UCorrected <br />0.00 <br />Name <br />Revenue Agent <br />Title <br />County <br />Hall <br />VERNE 0. HICKOK <br />Street or Other Mailing Address <br />412 SUEZ ST. <br />City <br />CAIRO <br />0.00 <br />Hall IEI004 /011 <br />PLEASE DO NOT WRITE IN THIS SPACE <br />TAXPAYER NAME AND MAILING ADDRESS <br />154.81 <br />.5 Jot. <br />Da e <br />NE Sec of Stale John A <br />State <br />NE. <br />Revenue Senior Agent <br />Authorized Signature Title Date <br />4-494-1974 Rev. 2 Supersedes 4.494 - 1974 Rev. 10-1995 <br />ale - UCC <br />Pgs: <br />9913715760 - 8 <br />HICKOK VERNE 0. <br />Filed: 05/23/2013 02:39 PM <br />Zip Code <br />68824 <br />154.81 <br />0.21 <br />5.08 <br />0.74 <br />134.07 <br />397.81 <br />$ 692.72 <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 the taxpayer has ailed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of an <br />effective lien, it se o continue the priori the state's interest in the affected property of he taxpayer. <br />Telephone Number <br />STL <br />1 <br />Spouse's Social Security Number <br />09/01/2010 11/03/2010 <br />09/30/2010 <br />10/01/2010 <br />11/30/2010 <br />12/01/2010 <br />12/31/2010 <br />01/01/2011 <br />02/28/2011 <br />03/01/2011 <br />08/31/2011 <br />02/07/2011 <br />02/02/2011 <br />08/04/2011 <br />11/02/2011 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />113.13 <br />282.29 <br />0.21 <br />5.08 <br />0.74 <br />20.94 <br />0.00 <br />115.52 <br />TOTAL <br />402 471 -6067 <br />