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04/23/2004 16:16 FAX 14024714429 NEBRASKA UCC IA 003 /004 G� 200404076 or 4� NOTICE OF STATE TAX LIEN This Notice of State Tax Lien is issued by the Nebraska Department of PLEASE DO NOT WRITE IN THIS SPACE 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 hereafter acquired. Nebraska Identification Number Lien Filed With Social Security Number Spouse's Social Security Number 99976706 QX Register of Deeds � County Clerk curl Serial Number Lien Type Date of Lien County 031920137 XQOriginal Continuation Corrected 04/20/2004 Hall BUSINESS NAME AND LOCATION ADDRESS 4Name TAXPAYER NAME AND MAILING ADDRESS Business Name NICANDRO VARGAS FLORES Street Address or Other Mailing Address City State Zip Code City 613 AVE 9 State Zip Code Tax DODGE CITY KS 67801 Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of Number Assessment Assessment Due 22 1999 11/28/2002 307.00 37.85 219.72 564.57 TOTAL $ 564.57 1 hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in the 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 Ta 'en s an extenslo n effective lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. ► Revenue Agent j�'Zd tU 402 471 -5713 sign Pre re Signature Title Date Telephone Number / here Revenue Senior Agent p r c Au orized Sire Title at gn u L..' 4494 -1974 Rev. 2 -2002 Supersedes 4 -494-1974 Rev. 10 -1994