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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. Department of of the state of and specified a lien to the taxpayer PLEASE DO NOT WRITE IN THIS SPACE I PLEASE RETURN TO: NEBRASKA DEPT OF REVENUE , PO BOX 94609 • LINCOLN NE 68509 4609 Nebraska oration Number 40996905 Lien Sena) Number 11315241 Lien Filed With Federal Identification _ — County Clerk Number Social Secuily Number XXX -XX -1483 Spouse's Social Seprily utrer j Register et Deeds • Date . = 10/02/2013 lien kJOriginal ype HALL ■ Continuation ■ Corrected BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MEWLING ADDRESS • LARRY BEHRENS • 624 S ELM ST GRAND ISLAND NE 88801 Tax • Category Number Tex Period Date of Assessment Amount of Tax Penally Interest Additions Balance of Assessment Duo 22 2009 07/15/2013 4,253.00 1,063.25 673,49 5,969.74 • that to be due. and tiro TOTAL $ 5,989.74 I hereby rarii1y amount shovel a Department of Revenue has complied wGh the revenue laws of the State of Nebraska in the determination rardoavor ha6'fa:'1 4 In n v thn a:rened dim 2dFnr danyvl If .1,6 N„P,.a ,.f anus T.., I L... I. a.. of r — :......r.... Oct. 7. 2013 2:32PM NE Secretary of State — UCC sign here 201308164 effective Gen, it serves to interest in the effected property of the taxpayer. Revenue Agent Revenue Supervisor Title No. 1332 P. 2/2,� .5Th s.� . ..... Jenn R — - BEHRENS LARRY Filed: 10/0712013 01:50 PM Nebraska •Department of REVENUE NOTICE OF STATE TAX LIEN w.N, w.revenue.ne.(1ov • Data 4.494.19)4 Rev. 2-2002 supersedes 4 -494.1914 Rev.10-1995