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07/08/2005 15:01 FAX 14024714429 <br />flS <br />NEBRASKA UCC <br />Please return to: <br />STATE OF NEBRASKA <br />DEPARTMENT OF REVENUE <br />1811 WEST 2ND ST STE 460 <br />GRANDASF.AND NE 68803 I <br />or <br />IM 002/002 <br />N! fee of stnje - YCC STL <br />9901540579 -8 Pas: 1 <br />Fllled5 07//08/2005 10:48 AFI <br />NOTICE OF STATE TAX LIEN <br />This Notice of State Tax Lien is issued by the Nebraska Department of PLEASE DO NOT WRITE IN THIS SPACE <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 />9356649 <br />Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number <br />Xn Register of Deeds ❑ County Clerk 503 -88 -6271 <br />Date ai Lien Lien Type County <br />06/25/2005 x0 original Q Continuation Corrected Hall <br />BUSINESS -NAME AND LOCATION ADDRESS' TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br />Street Address <br />City <br />Tax <br />Category <br />Number <br />State Zip Code <br />Tax Perlod Date of Amount of lax <br />01 101/0112 <br />12/ 31 20 04 I 05/22/2005 1,600.00 <br />Chad W Hedges <br />Street or Other Mailing Address <br />1008 E Nebraska r <br />State Zip Code <br />Grand Island NE 68801 <br />Penalty Interest Additions Balance of <br />Assessment 0 <br />320.00 75.94 1,995.94 <br />TOTAL $ 1,995.94 <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 is extension f an eff ective lien, it serves to continue the priority of the state's Interest in the affected property of the taxpayer. <br />► frJ) Revenue Senior A ent (y 3LF <br />i�gn Prep ref's Signet re Title Date Telephone Number <br />fete ► - - Revenue Su erviosr <br />Authoriz gn ure Title Da <br />4-094 -1974 Rev. 2 -2002 Supersedes 4A94-1974 Rev. 10-1995 i <br />