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01/14/2004 09:36 FAX 14024714429 NEBRASKA UCC Q 003 <br />fJJ <br />or <br />Wall* <br />* [Nil=y <br />200400408 <br />!!Fsibis - ucc <br />/2004 02:56 PM <br />NOTICE OF STATE TAX LIEN <br />PLEASE DO NOT WRITE IN THIS SPACE <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 Lien Filed With I Social Security Number Spouse's Social Security Number <br />10666648 El Register of Deeds [] County Clerk 485 -52 -1460 508 -64 -3344 <br />Lien Serial Number Lien Type Date of Lien County <br />031640021 Zoriginal []Continuation Corrected 01/06/2004 HALL <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br />DENZEL R & CHERYL BUSICK <br />Street Address Street or Other Mailing Address <br />7921 E 77TH PLACE <br />City State Zip Code City State Zip Code <br />TULSA OK 74133 <br />Tax <br />Category <br />Tax Period . <br />I <br />Date of <br />I <br />Amount of Tax <br />I <br />7 Penalty <br />Interest <br />Additions <br />I <br />Balance of <br />Number <br />Assessment <br />Assessment Due <br />22 I 2001 1 05/2212002 I 2,773.00 1 292.65 I 346.93 1 .1 3,412.58 <br />22 i 2002 1 03/25/2003 1 2,265.00 1 105.00 1 99.06 1 1 2,469.06 <br />I I I I I TOTAL ' I$ 5,881.64 <br />I hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska In the <br />determination of the amount shown to be due, and the taxpayer has failed to pay the amount due after demand. If this Notice of State F <br />Tax Lien an extensio f an effective lien, it serves to continue the priority of the state's intere t in the affected property of the taxpayer. ,lr <br />ft Revenue Senior Agent b OL{ 402 595 -2070 <br />sign 's Si itle Date Telephon Nu be f' ✓f <br />here Revenue Supervisor / D G' <br />Authorized Signatur Title Dat <br />4-494 -1974 Rev. 2 -2002 supersedes 4- 494 -1974 Rev. 10 -1995 <br />