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12/07/2004 10:52 FAX 14024714429 <br />PIMSC Mum 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�ti3KS . <br />dtiD;irtRROaI <br />gSiNrhivp <br />NEBRASKA UCC <br />Q003 <br />NE S.0 of 3 t - UCC <br />sn <br />990"4 -5 Pas; i <br />SALAZM EUGENE <br />Fitod: 12103/2004 02:22 PM <br />200411705 <br />NOTICE OF STATE TAX LIEN. <br />PLEASE DO NOT <br />This Notice of State Tax Lien is issued by the Nebraska Department of . <br />Revenue for unpaid to :as pursuant to the revenue Iaws -,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 acciulred. <br />IN THIS SPACE <br />Nebraska Identification Number Federal Identification Number <br />457019 47- 0523336 <br />Lien Serial Number — J Lien Filed With Social Security Number Spouse's Social Security Number <br />EE.Register of Deeds. County Clerk 359 -22 -7304 <br />Date of Lien Lien Type... ' County <br />11/29/2004 Q Original F� Conti nuation 0 Corrected Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br />Eugene Salazar <br />Street Address Street or Other Mailing Address <br />1415 Newcastle Road Apt #116 <br />City State Zip Code City State Zip Code <br />i;ranrl Iclanri Ne. 68801 <br />rcatTeag'ory <br />Tax Period <br />Date of <br />Amount of Tax <br />Penalty <br />Interest <br />Additions <br />Balance of <br />Number <br />Assessment <br />Assessment Due <br />01 01/0 1 /2002 11/03/2004 433.93 62.91 26.43 523.27 <br />12/31/2003 <br />TOTAL. $ 523.27 <br />I hereby certify that the Nebraska. Department of_Revenue has complied with the revenue laws of the State of- Nebrask' 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 i n nsion of an e e lien, it serves to continue the priority of the state's interest in the affected propelty of the taxpayer. <br />Revenue Agent /1__/0 / jo5� 308 385 -6075 n <br />Title Date Telephone Number <br />sign Prepa�atu here Date Senior Revenue Agent v Authorized gnaue Title <br />494.1974 Rev. 2 -20D2 Supersedes 4'494'1974 Rev- 10.1995 <br />T <br />