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11/17/1004 17:31 FAX 14024714429 <br />:r <br />Please return to: <br />STATE OF NEBRASKA <br />DEPARTMENT OF REVENUE <br />1811 WEST 2ND ST STE 460 <br />GRAND ISLAND NE 68803 <br />or - <br />ai�lfixsku <br />�oi>oi►t <br />NEBRASKA UCC <br />200411215 <br />lih 0061010 <br />STL <br />01;36 PM <br />NOTICE OF STATE TAX LIEN <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 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 Federal Identification Number <br />8876541 <br />Lien Serial Number Lien Filed With Social.Security Number Islous Social Security Number <br />C>q:1 11 3�" Ox Register of Deeds County Clerk 571 -57 -7339 - <br />Date of Lien Lien Type County <br />11/10/2004 Q Original O Continuation O Corrected Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br />Brandon Sayavong <br />Street Address Street or Other Mailing Address <br />724 West Third S_ teet <br />City State Tip Code City State Zip Code <br />Grand Island NE 68803 <br />Tax <br />Category <br />Tax Period <br />I <br />Date of <br />I <br />Amount of Tax <br />I <br />Penalty <br />I <br />Interest <br />I <br />Additions <br />I <br />Balance of <br />I <br />Number <br />Assessment <br />Assessment Due <br />01 1 4101 /2004 1 06/03/2004 1 1,169.80 1 233.96 I 63.98 I I 1,467.74 <br />TOTAL $ 1,467.74 <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 is an exAAtension of a effective ien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. <br />Revenue Senior Agent 11/10/2004 385 -6073 <br />.F /1 <br />sign Preparer's Signature Title Date Telephone Number <br />here 10. Revenue Supervisor 11/10/2004 <br />ized g ure Title Date <br />