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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 />City <br />sign <br />here <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 />113.3 /5 <br />Date of Lien <br />04/30/2013 <br />Business Name <br />Street Address <br />01 <br />01 <br />01 <br />01 <br />01 <br />01 <br />06/30/2010 09/07/2010 <br />Lien Filed With <br />Lien Type <br />EI <br />BUSINESS NAME AND LOCATION ADDRESS <br />State zip Code <br />Prep er's Signature <br />uthorized Signature <br />2 01304120 <br />ta�tif k. ItimpartmaI.a ae <br />REVENUE NOTICE OF STATE TAX LIEN <br />In WW.Y*V *Rf .c*. R10.411O1/ <br />Register of Deeds !County Clerk <br />Federal Identification Number <br />Original EContinuation OCorrected <br />0.00 <br />Name <br />Revenue Agent <br />Title <br />-ma <br />'Social Security Number <br />County <br />DAVID T. HICKOK <br />Street or Other Mailing Address <br />1678 WILD FLOWE <br />City <br />TWIN FALLS <br />0.00 <br />Hall <br />PLEASE DO NOT WRITE IN THIS SPACE <br />154.81 <br />Hall <br />TAXPAYER NAME AND MAILING ADDRESS <br />Da e <br />State <br />ID <br />Revenue Senior Agent <br />Title Date <br />4-494-1974 Rev. 2 -2002 Supersedes 4-494 -1974 Rev. 10-1995 <br />IJ007 /011 <br />NE See of Sts e John A Gs e - UCC ST <br />fill 1111 <br />9913715763 -4 Pgs: 1 <br />HICKOK DAVID T. <br />Fi ed: 05/23/2013 02:51 PM <br />Spouse's Social Security Number <br />Zip Code <br />83301 <br />09/01/2010 <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 />11/03/2010 <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 />0.00 <br />113.13 <br />282.29 <br />0.21 <br />5.08 <br />0.74 <br />20.94 <br />115.52 <br />TOTAL <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 his Notice of State Tax Lien is an extension of an <br />effective lien, it se 9to continue the prior f the state's interest in the affected property of he taxpayer. <br />402 471 -6067 <br />Telephone Number <br />5-02/— <br />