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City <br />Jul. 25. 2013 2:39PM NE Secretary of State — UCC No. 0120 P. 2/5 <br />Business Name <br />Street Address <br />BUSINESS NAME AND LOCATION ADDRESS <br />Tax <br />Category Tax Period <br />Number <br />01 <br />sign <br />here <br />03/01 /2013 <br />03/31/2013 <br />rized Signature <br />Date of <br />Assessment <br />05/01/2013 <br />State Zip Code <br />Amount of Tax <br />1,308.08 <br />201.3 <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 />10586679 <br />Lien Serial Number Lien Flied With <br />/1365,3V.7 ©Register of Deeds OCounty Clerk <br />UDat0 of Lien. Lien Type <br />07/19/2013 []X Original Continuation Corrected <br />!Rwbr.eR. Tlep4.1 morst iM <br />REVENUE NOTICE OF STATE TAX LIEN <br />WrVK'.Y+'Vi h•��.r �. dleM <br />Federal Identification Number <br />Name <br />City <br />80- 0439865 <br />Social Security Number <br />XXX -XX -9740 <br />TAXPAYER NAME AND MAILING ADDRESS <br />GARY LEMBURG <br />Street or Other Mailing Address <br />2805 FT. WORTH AVE. <br />GRAND ISLAND <br />Penalty <br />117.43 <br />PLEASE DO NOT WRITE IN THIS SPACE <br />County <br />Hall <br />Interest <br />6,56 <br />TOTAL <br />I hereby ce ' that the Nebraska Department of Revenue has complied with the revenue laws of the Slate of Nebraska in the determination of the <br />amount shown to be due, end the taxpayer has failed to pay the amount due after demand. If this Notice of State Tax Lien is en extension of en <br />effective lien, It Aiii nuns the prIo - state's Interest in the effected property of the taxpayer. <br />/ Revenue Agent ,s p,(' 402 471 -6067 <br />NE Sae of St.i. Jahn A e.l. - UGC ETL <br />11 1 1 1 11 11 1111 <br />9913719577-3 P9s: 1 <br />LEMBURG GARY <br />Filed: 07/25/2013 10;28 RR <br />Spouse's Social Security Number <br />Stale Zip Code <br />NE. 68803 <br />Additions <br />Balance of <br />Assessment Due <br />1,432.07 <br />1,432.07 <br />Title r .le Telephone Number <br />evenue Senior Agent 7) 3 — <br />Title Date <br />4494 -1974 Rev. 2 Supersedes 4-494-1974 ROC 10 -1946 <br />