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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 15:38 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 />/ )3345 - l:4 <br />Date of Lien <br />Business Name <br />Street Address <br />City <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 />0.00 <br />163.87 <br />336.39 <br />25.00 <br />0.00 <br />46.08 <br />33.64 <br />0.19 <br />7.53 <br />5.21 <br />100.00 <br />120.00 <br />300.00 <br />TOTAL <br />01 <br />01 <br />01 <br />01 <br />04/30/2013 <br />05/01/2012 07/02/2012 <br />05/31/2012 <br />Lien Filed With <br />D <br />Lien Type <br />BUSINESS NAME AND LOCATION ADDRESS <br />State Zip Code <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 - s 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, • continue the pr '•- of the slate's interest in the affected property of he taxpayer. <br />Revenue Agent ,_rJ o% <br />sign Preparer's Title to <br />here 4t- & Senior Agent <br />Signature <br />Autliorized Signature <br />201304127 <br />Nwbrasks Oesparlm#ni *0 <br />REVENUE NOTICE OF STATE TAX LIEN <br />www . +.v,►rh �rer. r..r.. <br />Register of Deeds I (County Clerk <br />Original 0Continuation ri Corrected <br />Title <br />Federal Identification Number <br />Name <br />Social Security Number <br />XXX -XX -9614 <br />County <br />Hall <br />DONN & VICTORIA HICKOK <br />Street or Other Mailing Address <br />PO BOX 133 <br />City <br />CAIRO <br />0.41 <br />Hall 0008/011 <br />NE Sec of <br />Static John p Gale - OCC <br />POE <br />9913715764 - 6 <br />HICKOK DONN <br />Filed: 05/23/2013 02:51 PM <br />PLEASE DO NOT WRITE IN THIS SPACE <br />STL <br />Spouse's Social Security Number <br />XXX -XX -0022 <br />TAXPAYER NAME AND MAILING ADDRESS <br />State <br />NE. <br />$ 1,138.32 <br />Telephone Number <br />2,1-i <br />Date <br />Date <br />4.494 -1974 Rev. 2-2002 Supersedes 4.494 -1974 Rev. 10 -1995 <br />Zip Code <br />68824 <br />25.41 <br />100.19 <br />337.48 <br />675.24 <br />402 471 -6067 <br />