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04/27/2005 16 ;15 FAX 14024714429 NEBRASKA UCC t l W} . i~ w Isftt�e= Ile sac o 111 99053! iFCE11 �R 200503811 IM 002/002 STL 2712005 10!21 AM NOTICE OF STATE TAX LIEN 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 hereby given that taxes including penalties and interest, which are shown below, are due from the taxpayer specified below and remain unpaid after demand. These taxes constitute a lien in the county for real and personal property belonging to the taxpayer or hereafter acquired. Nebraska identification Number Federal Identification Number 32065345 Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number 43450090 ❑X Register of Deeds ❑ County Clerk 507 -11 -442$ Date of Lien Lien Type I County 04/26/2005 ❑X Original ❑ Continuation ❑ Corrected HALL BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS Business Name Name CHAD KEEZER Street Address Street or Other Mailing Address 909 W SOUTH FRONT ST APT 2 City State Zip Code City State _ zip Code GRAND ISLAND NE 68801 Tax, Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of Number Assessment Assessment Due 22 2001 07129/2004 875.00 56.70 231.53 1,163.23 TOTAL. $ 1,163.23 I hereby certify that the Nebraska Department,of Revenue has complied with the revenue laws of the State of Nebraska in the determination of the amount sho to be due, and the taxpayer has failed to pay the amount due after demand- If this Notice of State Tax Lien is sion of a dive lien, it serves to continue the priority of the state's interest In the affected property of the taxpayer. evenue Agent Z1. yA0(i; 402 471 -5835 sign ' guth,'d 7SIgature re Title Date Telephone Number here Senior Revenue Agent Title Date n f