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u <br />11/30/2004 18:13 FAX 14024714429 NEBRASKA UCC 0006/006 <br />Or <br />2004115'75 <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 />28101219 <br />Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number <br />30450343 E Register of Deeds [:] Caunty Clerk 5OB -96 -3287 <br />Date of Lien Lien Type Ceunty <br />: 11 /24/2004 XO Original � Continuation F1 Corrected HALL <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br />BRADLEY T BENNER <br />Street Address Street or Other Mailing Address <br />249 SOUTH VINE ST <br />City State Zip Code City State Zip Code <br />rzpam l ISI 4AIr1 nic coon4 <br />Tax <br />— <br />- - -- <br />Category <br />Tax Period <br />Date of <br />Amount of Tax <br />Penalty <br />Interest <br />Additions <br />I <br />Balance of <br />Number <br />Assessment <br />Assessment Due <br />22 2001 11/1 9/2002 770.00 619.00 290.77 T1 1,679.77 <br />' I I TOTAL I $ 1,679.77 <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 gg extension of n effectvq li n, it serves to continue the priority of the state's interest in the affected property of the taxpayer. - <br />REVENUE AGENT / 402 471 -5835 <br />sign Prepare ' Signature Title Date Telephone Number <br />0. here..��.�.e r <br />thorized Sign at re Title Date <br />r <br />4494 -1974 Rev. 2 -2002 Supersedes 4- 494-1974 Rev. 10 -1995 <br />