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03/29/2005 17:52 FAX 14024714429 NEBRASKA UCC IM003/003 <br />MW <br />m96tYMr�dt <br />tlrrNMCgiA4 <br />200502745 <br />ME s.c o� xf.i! - lKC <br />STL <br />I <br />SMITH ITH 86502 -6 <br />R JAMES Pss` 1 <br />Filed: 03128/2005 11:08 AM <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 />12009385 <br />Lien Serlal Number Lien Flied With Social Security Number Spouse's Social Security Number <br />50560044 Z Register of Deeds County Clerk 505 -70 -9724 <br />Date of Lien Lien Type County <br />03 -25 -2005 XOOriginal ❑Continuatlon Corrected HALL <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br />R JAMES SMITH <br />Street Address Street or Other Mailing Address <br />1823 WEST 3RD <br />City State Zip Code City ..State Zip Code <br />GRAND ISLAND NE 68803 <br />Tax <br />Category <br />Tax Period <br />I <br />Date of <br />I <br />Amount of Tax <br />Penalty <br />Interest <br />I <br />Additions <br />I <br />Balance of <br />I <br />Number <br />Assess <br />Assessment Due <br />22 22 05-09 -2003 272.00 178.85 78.37 529.22 <br />22 2003 06 -09 -2004 552.00 39.60 31.21 622.81 <br />TOTAL $ 1,152:03 <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 i fenslon ffecdve lien, it s rves to co a the priority of the state's interest in the affected property of the taxpayer. <br />Revenue Agent 402 471 -5835 <br />$Igo Prepar 's Signature Title Date Telephone Number <br />here Senior Revenue A ent • 6s"-4-5-- <br />y d � <br />A thorized Sig tore Title Date /� <br />