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01/07!2004 17:49 FAX 14024714429 NEBRASKA UCC 11002!002 V� please return to: STATE OF NEBRASKA. DEPARTMEIti" T OF REI'ENICE— 1811 WEST 2ND ST STE 460 GRAND ISLAND NE 65803 Or 0 Q 200400208 sr_ ! 1 !t Paz: 1 f PM NOTICE OF STATE TAX LIEN DO NOT WRITE IN THIS This Notice of State Tax Lien is issued by the Nebraska Department of Revenue for unpaid taxes pursuant to the revenue laws of the state of Nebraska. Notice Is hereby given that taxes including penalties and Interest, which are shown below, are due from the taxpayer specified below and remain unpaid after demand. These taxes constitute a lien in the county for real and personal property belonging to the taxpayer or hereatter ac wreu. Nscraska Identification Number 39557618 Lien Filed With X[] Register of Deeds I Social Security NLMber D County Clerk ' 505 -04 -1181 Spouse's Social Security t rnoer Len Serial Number 032270249 Lien Type Original ❑CbnGnuation ElCorre ted Date of Llen 07/0512004 County I Hall BUSINESS' NAME AND LOCATION ADDRESS �- S -jy'a:ess Name TAXPAYER NAME AND MAILING ADDRESS Name Shane T Talcott Street Address Street or Other Meiling Address PO Box 776 C ty State 71p Code I City Grand'siand State Zip Coce NE 68802 Tax Category ! Number Tax Period Date of Assessment Amount of Tax Penalty Interest Additions Balance of Assessment Due 22 2002 05123/2003 1,563.00 112.15 68.09 1,74324 I _. TOTAL _f hP a Cut. of Rjah,nsir5i $ 1,743.24 In the 1 hereby certfly. that the Nebraska Department or Kavenue rids uump,1— w L,1 .,+_ 1= v.. �• •� u� - _ determination' of-the amount shown to be due, and the taxpayer has failed to pay the amount due after demand if this NCtICe of State ,/- Telc Lie ?next . 'un Dt an �`f Ii e r I± =ernes to mritinuE the pr or, of t e StStc S I^tereSt in the aff8.tfd pro; °nr et tre "dXp2y2r. +1� 1�nfr9l ✓G/� TSS ,�'i/ T 308 3fumber fit. 5tg11 Prep er's Signature Title Date elephone Numher ' here `Revenue Supervisor ! diorzed r u Title ate 4-404-197A Rev. 1 -2071 5uporeadaa "94-1q%4 R¢,