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08/13/2004 17:08 FAX 14024714429 o,;! tr d" W NEBRASKA UCC 200408101 IM 003/003 ROSS C Filed: NOTICE OF STATE TAX LIEN This Notice of State Tax Lien is issued by the Nebraska Department of 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 acnuirad_ NOT WRITE IN THIS SPACE Nebraska identification Number 41412826 Lien Filed With X❑ Register of Deeds E] County Clerk Social Security Number 480 -54 -5106 Spouse's Soclal Security Number Lien Serial Number 041412826 Lien Type Date of Lien XD Original [] Continuation Corrected 08109/2004 1 County HALL BUSINESS NAME AND LOCATION ADDRESS Business Name TAXPAYER NAME AND MAILJNG ADDRESS Name CONNIE D ROSS Street Address Street or Other Mailing Address 223 RED COACH CT City State Zip Code City State Zip Code SANFORD FL 32773 Tax Category Number 22 T 2000 Date of Assessment 11/0412003 Amount of Tax 5,099.08 Penalty 254.95 Interest 1,277.84 Additions Balance of Assessment Due 6,631.87 TOTAL Is 6,631.87 I hereby certify that the Nebraska Department of Revenue has complied wlth 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 " Tax Lien is pn extension of an effective lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. ► Revenue Agent 9`c/ -{ �/ 402 471 -5835 sign ju repar rs Signature Title Date Telephone Number here ► lrs>:�o,e �1� -off t honzed Signa re Trtie Date tt