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Tax <br />Category <br />Tax Period <br />Date of <br />Amount of Tax <br />Penally <br />Interest <br />Additions <br />Balance of <br />Number <br />Assessment <br />Assessment Due <br />6 <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 Hen <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 <br />/13 bs <br />Date of Lien <br />07/19/2013 <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 />Jul, 25. 2013 2:40PM NE Secretary of State — UCC No. 0120 P. 4/5 <br />BUSINESS NAME AND LOCATION ADDRESS <br />thorixed Signature <br />Lien Filed With <br />Register of Deeds ( (County Clerk <br />Lien Type <br />PiwbraVkr .'?eosr¶rr.�nf pf <br />REVENUE NOTICE OF STATE TAX LIEN <br />w�.w ►►tern '..,r•r.d4' <br />[8]Original OContinuation DCorrected <br />State Zip Code <br />201305998 <br />Federal Identification Number <br />Name <br />80- 0439865 <br />Social Security Number <br />XXX -XX -9740 <br />TAXPAYER NAME AND MAILING ADDRESS <br />GARY LEMBURG <br />County <br />Hall <br />Street or Other Mailing Address <br />2805 FT. WORTH AVE. <br />City <br />GRAND ISLAND <br />03/01/2012 04/23/2012 <br />03/31 /2012 <br />04/01/2012 <br />04/30/2012 <br />05/01/2012 <br />05/31 /2012 <br />06/01/2012 <br />06/30/2012 <br />07/01/2012 <br />07/31/2012 <br />06/01/2012 <br />06/21/2012 <br />07/23/2012 <br />08/21/2012 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />10/16/2012 <br />08/01 /2012 <br />08/31/2012 <br />0.00 <br />68.46 <br />0.00 <br />0.00 <br />0.00 <br />16.67 <br />15.66 <br />15.05 <br />13.27 <br />5.05 <br />52.55 <br />10.06 <br />TOTAL <br />I hereby certify 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, and the taxpayer has failed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of an <br />effective Tien, it se ' continue the prio • y. the state's interest In the affected properly of the taxpayer. <br />Revenue Agent <br />Title <br />PLEASE DO NOT WRITE IN THIS SPACE <br />7 <br />Spouse's Social Security Number <br />Stale <br />NE. <br />Zip Code <br />68803 <br />16.67 <br />84.12 <br />15.05 <br />13.27 <br />5.05 <br />62.61 <br />3 196.77 <br />402 471 -6067 <br />Telephone Number <br />Revenue Senior A gent 7-0) j- /j <br />Title Date <br />4-494 -1974 Rev. 2-2002 5upereedee 4-194 -1974 Rev. 10-1995 <br />