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Tax <br />Category <br />Tax Period <br />Date of <br />Amount of Tait <br />Penalty <br />Interest <br />Additions <br />Balance of <br />Number <br />Assessment <br />Assessment Due <br />Jul. 25. 2013 2:40PM NE Secretary of State — UCC <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 />5'3 <br />Dale . ien <br />Business Name <br />Street Address <br />City <br />01 <br />01 <br />0 1 <br />01 <br />01 <br />01 <br />10586679 <br />07/19/2013 <br />07/01/2010 03/29/2013 <br />05/31/2011 <br />sign • reps ers Signature <br />here du II <br />uthorizlsd Signatur <br />REVENUE NOTICE OF STATE TAX LIEN <br />Lien Filed With <br />BUSINESS NAME AND LOCATION ADDRESS <br />Register of Deeds OCounty Clerk <br />Lien Type <br />®Original f Continuatio <br />Std a Zip Code <br />0.00 <br />Revenue Agent <br />Title <br />Title <br />201305999 <br />Federal Identification Number <br />Name <br />Corrected <br />Revenue Senior Agent <br />80 -0439865 <br />GARY LEMBURG <br />Street or Other Melling Address <br />2805 FT. WORTH AVE. <br />City <br />GRAND ISLAND <br />1,052.75 <br />No.0120 P. 5/5 <br />9913719580 -0 <br />l-EnsURG GARY <br />Filed 07/25/2013 10:26 <br />PLEASE DO NOT WRITE IN THIS SPACE <br />Social Security Number <br />XXX -XX -9740 <br />Co unty <br />Hall <br />Spouse's Social Security Number <br />TAXPAYER NAME AND <br />MAILING ADDRESS 1 <br />State <br />NE. <br />06/01 /2011 <br />01/03/2012 <br />09/30/2011 <br />10/01/2011 02/02/2012 <br />11/30/2011 <br />12/01/2011 <br />12/31/2011 <br />01/01/2012 <br />01/31/2012 <br />02/01/2012 <br />02/29/2012 <br />01/22/2012 <br />02/2012012 <br />04/02/2012 <br />0.00 <br />0.00 <br />0.00 <br />0.00 <br />188.85 <br />52.94 <br />0.00 <br />0.00 <br />25.00 <br />502.10 <br />73.48 <br />16.48 <br />13.90 <br />12.25 <br />0.00 <br />25.45 <br />TOTAL <br />1,554.85 <br />262.33 <br />69.42 <br />13.90 <br />12.25 <br />50.45 <br />$ 1,963.20 <br />1 hereby certifythat t i Nebraska Department of Revenue hes compiled with the revenue Taws of the State 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 Stale Tax Lien is an extension of an <br />effective Hen, It servey j� . tine the p . the slate's interest in the affected property of the taxpayer. <br />Telephone Number <br />—� 3.r/ <br />Date <br />4- 494 -1974 Rev. 2,2002 Supersedes 4494-1974 Rev, 10-1995 <br />68803 <br />AM <br />Zip Code <br />402 471.6067 <br />