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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 15:38 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 />Lien Serial Number <br />1/33Ass1 <br />Date of Lien <br />Business Name <br />Street Address <br />City <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 />113.13 <br />282.29 <br />0.21 <br />5.08 <br />0.74 <br />20.94 <br />115.52 <br />TOTAL <br />0.00 <br />01 <br />01 <br />01. <br />01 <br />01 <br />01 <br />sign <br />here <br />10290958 <br />04/30/2013 <br />01/01/2010 09/07/2010 <br />06/30/2010 <br />BUSINESS NAME AND LOCATION ADDRESS <br />horized Signature <br />201 304129 <br />Lien Filed With <br />Lien Type <br />NObrasi s Cl000rt:ri of <br />REVENUE NOTICE OF STATE TAX LIEN <br />wvNM :J. Y!nvi. .-W.QOv <br />Register of Deeds UCounty Clerk <br />Original EjContinuation Corrected <br />State Zip Code <br />0.00 <br />Name <br />Revenue Agent <br />Title <br />Federal Identification Number <br />Street or Other Mailing Address <br />PO BOX 133 <br />City <br />CAIRO <br />0.00 <br />�Hy <br />Hall <br />NE Sec of State John A Gale <br />UCC STl <br />991371 -0 <br />P9s: 1 <br />HICKOK DONN <br />Fired= 05/2312013 02:51 PM <br />PLEASE DO NOT WRITE IN THIS SPACE <br />Social Security Number <br />XXX -XX -9614 <br />County <br />Hall <br />Spouse's Social Security Number <br />XXX -XX -0022 <br />TAXPAYER NAME AND MAILING ADDRESS <br />DONN & VICTORIA HICKOK <br />154.81 <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 serves continue the pr' f the state's interest in the affected property of he taxpayer. <br />ate <br />o/ <br />State <br />NE. <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 />402 471 -6067 <br />Telephone Number <br />5 1- /3 <br />Revenue Senior Agent <br />Title Date <br />4 -494 -1974 Rev. 2-2002 Supersedes 4-494 -1974 Rev. 10 -1995 <br />lZo / <br />