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12/08/2004 11:21 FAX 14024714429 <br />JJJ Y <br />Pleaseretum to: <br />STATE OF N1 BRASKA <br />DEPARTMENT OF REVENUE <br />1811 WEST 2ND ST STE 460 <br />GRAND ISLAND Nt 68803 <br />NEBRASKA UCC <br />200418401 <br />Idl 003/005 <br />NE S.e of Sk.i• - UCC STL ' <br />9904364205 —a PpE: 1 <br />VENTURA MARGARITA <br />Filed: 12/07/2004 12:23 PM <br />111're NOTICE OF STATE TAX LIEN <br />PLEASE DO NOT WRITE IN THIS SPACE <br />This Notice of State Tax ilien is issued by the Nebraska Department of <br />Revenue for unpaid taxel pursuant to the revenue laws of the state of <br />Nebraska. Notice is hereby given that taxes including penalties and . <br />interest, which are show 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 />9253572 <br />Lien Serial Number Lien Fled With - Social Security Number Spouse's Social Security Number <br />Register of Deeds E] County Clerk 506 -29 -5635 <br />Date of Lien Lien Type 7Hall ED Original FIContinuation E] Corrected <br />BUSINESS NAME ,D LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br />Margarita Ventura <br />Street Address' Street or Other Mailing Address <br />217 S Oak Street <br />City State Zip Code I City State Zip Code <br />Grand Island NE 68801 <br />Tax <br />Category <br />Tax Period <br />I <br />I <br />Date of <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 D <br />e <br />01 1 01/31/2004 1 10/24/2004 300.00 + 80.00 14.02 I 394.02 <br />I hereby certify that the N <br />determination of the amou <br />Tax Lien is an extension c <br />Sigh Preparer's Signatuf <br />here <br />Authoriz g tut <br />TOTAL $ 394.02 <br />-asks Department of Revenue has complied with the revenue laws of the State of Nebraska in the <br />shown to be due, and the taxpayer has failed to pay the amount due after demand_ If this Notice of State ! r <br />n effective lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer., <br />Revenue Senior Agent 12/01/2004 385 -6073 <br />Title Date Telephone Number <br />Revenue Supervisor / Z <br />Tide Date <br />11 <br />