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05/27/2005 16:22 FAX 14024714429 NEBRASKA UCC <br />NOR <br />or <br />Moto" <br />00400W <br />a�rreKai>io <br />Please return to: <br />STATE OF NEBRASKA <br />DEPARTMENT OF REVENUE <br />1811 WEST 2670 ST STE 460 <br />GgANI7 ISLAND NE 68803 <br />200504822 <br />10003/003 <br />W Sea of 346!8 - 1a[[ !TL <br />I <br />I <br />I <br />99 ®5396668 -8 <br />Pas: 1 j <br />WASHINGTON HENRY <br />Filed: 05/27/2006 09:29 AM <br />NOTICE OF STATE TAX LIEN <br />PLEASE DO NOT WRITE IN THIS <br />This Notice of State Tax Lion 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 penaltles 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 ac aired. <br />Nebraska Identification Number Federal Identification Number <br />j 31791174 <br />Lien Serial Number Lien Filed With social Security Number Spouse's Social Security Number <br />322 XnRegistarofDeeds • ❑County Clerk 505 -92 -1872 <br />Date of Lien • Lien Type County <br />05/26/2005 Koriginal Continuation Corrected Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br />Henry H Washington. <br />Street Address Street or Other Mailing Address <br />_ 503E 9th <br />City State Zip Code City State Zip Code <br />Grand Island NE 68801 <br />FTax Balance of <br />Category Tax Period Date of Amount of Tax Penalty Interest Additions Assessment Due <br />Number "Assessment <br />22 12/31/2003 06/0412004 219.00 10.95 14.62 244.57 <br />TOTAL =$244�57 <br />1 hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the Stale of Nebraska in the <br />determ tion 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 Li n i an extension O an effective lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. <br />Revenue Agent 05/26/2005 pho 385 067 <br />sign rep rers Signature Title Date Telephone Number <br />here Revenue Supervisor 05126/2005 <br />Title Date (k 1 Al <br />fA'uthorized ig at a i' , <br />