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08/03/2004 16:43 FAX 14024714429 NEBRASKA UCC <br />U <br />200407713 <br />i ON <br />k -- <br />monslo <br />01pa <br />of 014wW A <br />II <br />16 <br />141002/003 <br />Pas: I <br />10: 31 AM <br />NOTICE OF STATE TAX LIEN <br />DO <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 Federal Identification <br />8923027 Xl Register of Deeds E] County Clerk <br />WRITE IN THIS <br />Social Security Number <br />508 -92 -8675 <br />Lien Serial Numb r Lien Type Date of Lien County <br />O �%b f 3 I [ XQ Original Ej Continuation �Corr,,ted 08 102/2004 Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Name <br />Business Name <br />Kathleen C Davidson <br />Street Address Street or Other Mailing Address <br />2120 Chanticleer <br />City <br />State Zip Code j city <br />Category Tax Period Date of <br />Number Assessment <br />01 01/01/2003- 07106/2004 <br />03131/2004 <br />04/0112004- <br />01 06/30/2004 08/02/2004 <br />Amount of Tax <br />1,100.48 <br />270.30 <br />State Zip Code <br />Grand Island NE 68801 <br />Penalty Interest Additions _ Balance o <br />108.23 1 34.54 1 1 1,243.25 <br />27.03 -1 0.36 1 1 297.69 <br />TOTAL $ 1,540.94 <br />�• <br />I hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in, the i lr <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 �t ; <br />Tax Lien I an a densioq of an effective lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. ' <br />Revenue Senior Agent <br />2 308 385 - 607331 <br />Sign Preparer's ig a/ e <br />Title Date' Teiephone Number <br />here Revenue Supervisor O <br />_ D <br />Titla <br />