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12/08/2004 11:20 FAX 14024714429 NEBRASKA UCC Please return to: 200411841 STATE OF NEBRASKA DEPARTMENT OF REVF,NUE 1811 WEST 2ND ST STE 460 GRAND ISLAND NE 68803 IM 002/005 STL PUS! I PM Of N I NOTICE OF STATE TAX LIEN 1harukp dtpoetri"nt Of PQN<Ciltt7 PLEASE DO NOT WRITE IN THIS SPACE This Notice of State Tax Lien is issued by the Nebraska Department of Revenue for unpaid taxes pursuant to the revenue laws of the state of Nebraska. Notice is herlebly given that taxes including penalties and interest, which are sho below, are due from the taxpayer specified below and rem in unp id after demand. These taxes constitute a lien in the county f�r real a d personal property belonging to the taxpayer or hereafter acquired. Nebraska Identiticatl n Numbeir Federal Identification Number 90:6950 Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number �4 2 X❑ Register of Deeds [] County Clerk 459 -33 -3843 Date of Lien.:......._.. Lien Type, ounty Novemb e r 25, 20P4 17x original Continuation Corrected H211 Business Name Name Teresa D Urbina Street Address Street or Other Mailing Address 2903 W Stolley Park Road City I State Zip Code City State Zip Code (,rnnrllsfanrl N1= ARAM Tax Category Tax Period :Date of Amount of Tax Penalty Interest Addltlons Balance of Number Assessment Assessment Due 01 1 12(31/20031 10/24/04 ( 300.00 ' 55.00 I 13.79 I ` 368.79 TOTAL $ 368.79 1 hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in the determination of the amouni shown to be due, and the taxpayer has failed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of a an effective lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. 1 Revenue Senior Agent December 1, 200 3$5-6073 sign Preparers :gnat I Title Date Telephone Number here 0. Revenue Supervisor 2 c 6utho &ai lure) Title Dat