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05/04/2005 08:22 FAX 14024714429 <br />M <br />Please Temm to; <br />STATE OF NEBRASKA <br />DEPARTMENT OF REVENUE <br />1811 WEST 2N0 ST STE 460 <br />GRAND ISLAND NE 68803 <br />_J <br />NEBRASKA UCC <br />n Sac of <br />200504024 <br />Q002/002 <br />STL <br />Pas; I <br />04:07 PM <br />NOTICE OF STATE TAX LIEN <br />PLEASE; DO <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 acauired. <br />SPACE <br />Nebraska Identification Number Federal Identification Number <br />8876541 <br />Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number <br />� �` t' c3 <br />Register-of Deeds County Clerk 571 -57 -7339 <br />Date of Lien.. Lien Type County <br />04122/2005 E original 0Contlnuatlon Corrected Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS, <br />Business Name Name <br />Brandon Sayevong <br />Street Address Street or Other Mailing Address <br />724 West Third Street <br />City State Zip Code City State Zip Code <br />Grand Island NE 68801 <br />Tax <br />Category <br />Tax Period <br />Date of• <br />Amount of Tax <br />Penalty <br />Interest <br />Additions <br />Balance of <br />Number <br />Assessment <br />Assessment Due <br />01 U41ll1/YUU4- 04/22/2005 300.00 60.00 13.36 373,36 <br />06/30/2004 <br />01 07/01/2004- 04/22/2005 300.00 60.00 8.83 368.83 <br />09/30/2004 <br />1 I I I TOTAL Is 742.19 <br />I hereby certify .that the Nebraska Department of Revenue has compiled 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 is an extension of an effective lien, It serves to continue the priority of the state's interest in the affected property of the taxpayer. <br />Revenue Senior Aqent ��j� j'J 308 385 -6073 <br />sign Preparer's Signature Title �^ Date Telephone Number <br />here Revenue Su ervior <br />Authorize i ure Title Da <br />4-494 -1974 Rev. 2 -2002 Supersedes 4 -494 -1974 Rev. 10-1995 <br />_ l <br />