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12/08/2004 11:21 FAX 14024714429 <br />dq <br />NEBRASKA UCC <br />20041164` <br />U004/005 <br />or 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 aws of the state of <br />Nebraska. Notice is hereby given that taxes includi ig penalties and <br />interest, which are shown below, are due from the I axpayer specified <br />below and remain unpaid after demand. These taxe s constitute a lien <br />in the; county for real and personal property belong ng to the taxpayer <br />or hereafter acquired. <br />Nebraska Identification Number Federal Identification Number <br />99350661 <br />Lien Serial Number Lien Filed With Social.Security Number Spouse's Social Security Number <br />3330183 ❑X Register of Deeds [] County Clerk 507 -76 -6052 <br />Date oflien Lien Type County <br />11/2612004 X0 Original ❑ Contin ation 1:1 Corrected HALL <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Businis Name Name <br />KRISTY L RIDDLE <br />Street address Street or Other Mailing Address <br />840 MICKEY ST <br />City State Zip Code City State Zip Code <br />C)R(IFC)I A nic aoa94 <br />Tali <br />- <br />- <br />- , <br />eg <br />Ca'oy <br />Tax Period <br />Date of <br />Amount of Tax <br />Penalty <br />Interest <br />I <br />Additions <br />Balance of <br />umber <br />i <br />Assessment <br />Assessment Due <br />22i 1 2001 1 10/13/2003 I 95.00 I 1 12.25 I 41.28 ' I 148.53 <br />that the Nebraska Department of Rover <br />the amount shown to be due, and the t <br />xten*n of an eff.,ec4ive lien, it serves to <br />sign " prepar I s Signature <br />here <br />th l <br />ori ed Sig ature <br />Tide <br />- <br />Tile <br />1 TOTAL I$ 148.53 <br />complied with the revenue laws of the State of Nebraska in the �1 <br />has failed to pay the amount due after demand. If this Notice of State <br />e the priority of the state's interest in the affected property of the taxpayer. <br />IUE AGENT %/ aq -6y 402 471 -5835 <br />Date Telephone Number <br />Date <br />4-494 -1974 Rev. 2 -2002 Supersedes 4 -494 -1974 Rev. 10 -1995 <br />