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03/16/2004 16:54 FAX 14024714429 NEBRASKA UCC <br />Please return to: <br />STATE OF NEBRASKA <br />DEPARTMENT OF REVENUE <br />1811 WEST 2xD ST STE 460 <br />200402565 <br />GRAND ISLAND NE 68803 <br />air <br />NOTICE OF STATE TAX LIEN <br />Or rgMNIMO• <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 irevQnue. laws'of th,e.•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 />8061068 M Register of Deeds E] county Clerk 600 -60 -9937 <br />Lien Serial Number Lien Type Date of Lien County <br />—�O E Orlginal Continuation Corrected 03/15/2004 Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br />Bryan Hughes <br />Street Address Street or Other Mailing Address . . <br />1946 North 104th Drive <br />City State' Zip Code City State Zip Code <br />AvonrinlP A7 ft_;;14 914 <br />Z 008/008 <br />Tax <br />Category <br />Tax Period <br />I <br />Date of <br />Amount of Tax <br />Penalty <br />Interest <br />Additions <br />Balance of <br />Number <br />Assessment <br />Assessment Due <br />01 uoru ircVuu- 1 02%12/2003 1,642.74 377.48 543.78 2,564.00 <br />06/30/2000 <br />66 05/01/2000-1 02/12/2003 752.00 170.40 245.01 1,167.41 <br />06/30/2000 I. <br />I I I TOTAL 1$ 3,731.41 <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 <br />Tax Lien nIIspan/e/xtenslgn of an effective lien, it serves to continue the priority of the state's interest in the affect ,d property of the taxpayer. <br />Y1, J��`% % Revenue Senior Agent 308 385 -6073 <br />Sign rePareTs Slg6ature Title ` Date Telephone Number <br />here Revenue Supervisor o <br />uthorized 1g re Title'' <br />' 4-494 -1974 Rev. 2 -2002 Supersedes 4- 494 -1974 Rev, 10-1995 <br />