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L� <br />01/23/2004 17:06 FAX 14024714429 NEBRASKA UCC _ <br />Ptrsse rotwn to: <br />STATE OF NEBO <br />DEPARTMENT REVFNUE <br />1811 WEST 2T1D S STE <br />688030 <br />GRAND ISLAND NE <br />tr <br />elr4 <br />AopusAtiKYI- <br />of trwYtiae <br />U003/003 <br />NE He of 314a1. - UCC STL <br />-6514 1.114 1 111A oil 11.1 1111is ]11il in <br />I <br />i <br />1 <br />3DONRLD R Pgs: i <br />VANCE Filed: 01/23/2004 12:59 PM <br />200400753 <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 Social Security Number Spouse's Social Security Number <br />1308416 [X Register of Deeds County Clerk 507 -56 -8334 508 -70 -7054 <br />Lien Serial Number Lien Type Date of Lien County <br />E Onginal Continuation. E]Corrected 12/24/2003. , Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br />Donald R & Shirley L Vance <br />Street Address Street or Other Mailing Address <br />2408 Cottonwood Road <br />City State Zip Code City State Zip Code <br />rl_ NF 68801 <br />Tax <br />Category <br />Tax Period <br />Date of <br />Amount of Tax <br />Penalty <br />Interest <br />Additions <br />Assessment Due <br />Number <br />Assessment <br />01 07!0112002- 12/24/2003 23,758.46 2,395.31 1,163.35 27,317.12 <br />09/14/2003 <br />64 07/01/2002 12/24/2003 25.00 5.00 0.34 30.34 <br />06/30/2003 <br />21 07/01 /2003 12/24/2003 859.48 42.97 7.63 910,08 <br />07101/2003- <br />09/14/2003 <br />TOTAL $ 28,257.54 <br />.1, hereby certify that ttie Nebraska Department of Revenue.has complied with the revenue laws of the -State of Nebraska in the' r <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 <br />Tax lien is an a en 'on of a effe; ive lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. <br />1 308 385 -6073 <br />Revenue Senior A ent —T--5-5-9 rr <br />Sign Prepar is S "na ure Title Date 4Da unbar !z, <br />here Revenue Supervisor <br />orize S na re Title . <br />4- 494 -1974 Rev -2 -2002 Supersedes 4- 496 -'1974 Rev. lO -7995 <br />