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This Notice of. State Tax Lien is issued by the Nebraska Revenue for unpaid taxes pursuant to the revenue laws Nebraska. Notice is hereby given that taxes including penalties interest, which are shown below, are due from the taxpayer below and remain unpaid after demand. These taxes constitute in the county for real and personal property belonging or hereafter acquired. T Department of of the state of and specified a lien to the taxpayer PLEASE DO NOT WRITE IN THIS SPACE NebraskalWenkfication Number 41736273 Federal Identification Number Lien Serial Number 40090097 Lien Filed With NRe of Deeds • Canty Clerk Social Security Number XXX -XX -6661 Spouse's Serial Security Number Date of Lien 01/092004 Lien Type •Orighal G Continuation U Corrected County HALL BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS GUERRNDAVID V 422 N CLEBURN 3 GRAND ISLAND NE 68801 Tax Category Number Tax Period Date of Assessment Amount of Tax Penalty Interest Additions Balance of Assessment Due 22 2000 10/28/2003 345.48 17.27 74.48 .00 437.23 4. TOTAL $ 437.23 I hereby certify that the Nebraska amount shoran to be filla. and the Department o tarmaver has failed Revenue has complied with the revenue laws of the State of Nebraska in the determination of the to nay the aimir i dlwA efer damnrvl If thin Alrdirla ti asarp Tay I in re y, --- - .a a. Sep. 11. 2013 3 :27PM NE Secretary of State — UCC 20 1307441 Nebraska Department of REVENUE N www.revenue.he.gov TWF nF STA q 2 i ca i4 --3 Revenue Supervisor NE See of Ate le Jahn A 6A1 - ULE SLAW i I l �lll l I I� Ill iii I �,QI I u I I l I�' I I I I ij 9913722632 -6 1 1 OUERRA DAVID V Filed: 09/11/2013 02:30 PM No. 0871 P. 6/6 TAX LIEN