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11/19/2004 12:51 FAX 14024714429 <br />NEBRASKA UCC <br />200411270 <br />v, <br />U003/003 <br />9%2004 10:41 AM <br />NOTICE OF STATE TAX LIEN <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 />DO NOT WRITE IN THIS SPAUh <br />or hereafter ac uirea. <br />Federal Identification Number <br />Nebraska Identification Number F <br />23159081 <br />Lien Serial Number L <br />Lien Filed With S <br />Social Security Number Spouse's 5odal Security Number <br />40090217 X <br />X❑ Register of Deeds ❑ <br />❑ County Clerk 5 <br />505 -82 -7860 <br />Date of Lien L <br />Lien Type C <br />County <br />11/15/2004 ❑ <br />❑X Original ❑ Continuation ❑ Corrected I HALL <br />BUSINESS NAME AND LOCATION ADDRESS T <br />TAXPAYER NAME AND MAILING ADDRESS <br />Business Name N <br />Name <br />JERRY L BOWEN <br />Street Address S <br />Street or Other Mailing Address <br />RR 1 BOX 10 <br />City S <br />State Zip Code C <br />City State Zip Code <br />FRANKLIN NE 68939 <br />Tax <br />Category Tax Peri od D <br />Date of Amount of Tax P <br />Penalty Interest Additions Balance of <br />Number A <br />Assessment A <br />22 1 <br />11/2012003 2 <br />2,619.00 7 <br />734.00 7 <br />771.92 4 <br />4,124.92 <br />2000 <br />TOTAL $ <br />$ 4,124.92 <br />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 extension of an effecti a lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. �j 15�1 <br />REVENUE AGENT 11/15/2004 402 471 -5835 <br />sign =Preparqrs re Title Date Teiephone Number <br />here Title Date <br />ure 4-494 -1974 Rev. 2 -2002 Supersedes 4. 484 -1974 Rev. 10 -1995 <br />