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0 <br />10/06/2004 11:03 FAX 14024714429 NEBRASKA UCC Q 002 /002 <br />Please return to: <br />STATE OF NEBRASKA <br />DEPARTMENT OF REVENUE <br />1811 WEST 214D ST STE 460 <br />GRAND ISLAND NE 68803 <br />Or <br />nebraska <br />department, <br />of revenue <br />SOCs SEC* Nom <br />57397193 0. <br />NEBRe IDENTs NO* <br />38331386 <br />SPOUSE sore SEC* IgNap <br />TAXABLE YEAR <br />LIEN. NC* <br />#20�00 <br />046-650655 <br />COUNTY <br />. _ . HALL <br />DATE OF NOTICE <br />63/05/2.604 <br />DATE CF ASSESSMENT <br />261/1"2004 <br />THIS MICE OF STATE TAX LIEN <br />REVENUE. FOR INDIVIDUAL INC. <br />STATE OF NEMA59Aa DICE IS I <br />TAXES IHELiIDINIO PENALTIES A 7 <br />Fire THE TAXPAl�ER , SPECIFIED - ABI <br />THESE TAXES CCXSTI WL . A Lx_14' <br />TffE TAXPAYER OR HEREAFTER ACQ(£ <br />AMWHT Of TAX' a. , . .. a 4 6 <br />PENALTY-a . s'.. !.0 ! • W. <br />INTEREST . (C PUTED'. TC+ 031+ <br />TOTAL. 'Amount U E' a a a :: • <br />F HM -RERY CERTIFY. THAT TH-E . RE i <br />WITH, NE. RE.YENUE LAWS; DF THE S' <br />THE AM H3 SHDWH TD. BE DU-Er. AM <br />ARW1T ..DL'E AFTER DENAMDa T T! <br />EX i t NSIG OF AN . EFFEETIVE - LIEN <br />TIJE STATF' S INTEREST IN THE AF] <br />a _ a4i • <br />PREFAR •.S SIG `ATURE TITLE <br />- - 0.0le 0044... <br />AL*IH . D ST - ATURE TITLE <br />N[ Sm f s4.40 - UCC STL <br />III 11111 11111 1 1111 '11111111 11 <br />9904353595 -0 Ps:: , <br />DE LA ROSA ANTONIO <br />Filed: 10/08!2004 08:22 AM <br />200409829 <br />Notice of State Tax Lien <br />PLEASE DO NOT WHITE IN THIS SPACE <br />AL 4CO E T"._ <br />ANTONIO VF LA, RaSA <br />Too E 8TH <br />GRAND ISUM WE 6SMI <br />.S ISSUED BY THE NEBRASKA DEPARTHE DF <br />"AX PURSUANT TD THE REVENUE LAWS Of THE <br />IEREBY GIVEN THAT -LNDIV MAL INCGW- <br />:VMRFSTw WHICH ARE SHOWN BELOW ARE DUE. <br />IVE AM REMAIN UNPAID AFTER DEMAND* <br />:N THE COUNTY FOR PROPERTY BELONGIM TO <br />• a a. a s a a. s 4 a 0 Zfi005 <br />0 a 0 s le a a 4 a a s 664017 <br />SKA DEPARTWE OF REVENUE HAS C0I4PLIED <br />ATE Of NEBRASKA IH. THE DETERMINATI N OF <br />.THE TAXPAYER HAS FAILS TO PAY THE <br />IS NOTICE OF STATE TAX LIEN IS AN <br />IT SERVES TO CONIFfINUE THE PRIORITY OF <br />E£TED PROPERTY DF 114E TAXPAYER: <br />!!a!la afaa•aaai'�i4 <br />a s ialas aas•ae <br />f C E. <br />4 <br />� o <br />• s•a a! 40.00.04 <br />DATE <br />NEBRASKA DEPARTMENT OF REVENUE - White and Canary Copies TAXPAYER - Pink Copy <br />PMred with soy ink on raoyded paper 7.1455-1979 Rev. 2 -2000 Supersedes 7.145 -1979 Rev. 10-1995 <br />w <br />