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08/03/2005 08 :43 FAX 14024714429 NEBRASKA UCC <br />N9 set <br />N <br />200507506 <br />IM 002/002 <br />of Side - ucr 9TL <br />408139 -0 P ®s: 1 <br />2 GENRY <br />08/02/2005 03:10 PM <br />NOTICE OF STATE TAX LIEN <br />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 />8802297 <br />Hen Serial Number Lien Filed With Social Security Number Spouse's Social Security Number <br />OX Register of Deeds ❑ County Clerk 605 -56 -0549 <br />Date of Lien Lien Type County <br />07 -29 -05 Q original E] Continuation ❑ Corrected HALL <br />BUSINESS NAME AND LOCATION ADDRESS I TAXPAYER NAME AND MAILING ADDRESS <br />Business Name IName <br />GENRY MENDEZ <br />Street Address Street or Other Mailing Address <br />1114 N BROADWELL AVE <br />City State Zip Code I City State Zip Code <br />GRAND ISLAND NE 68803 <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 01 -01-03 02 -06 -04 1,000.31 145.03 96.32 1,241.66 <br />hru 12 -31 -0 <br />- <br />gET[3TtN COPY TO. <br />NEa XA DEPARTMENT SVX <br />A,rTVTION TAXPAYER <br />pO HOX 94609 <br />yzNCOLN NE 66506 + <br />OR FAX To: 902 -4'71 -5606 <br />TOTAL I$ 1,241.66 <br />1 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 extensio an effective lien, it serves to continue the priority of the state's Interest in the affected property of the taxpayer. <br />�.� Revenue Agent _ I— al- 200L 402 471 -5723 <br />sign Prepar ign r Title Date Telephone Number <br />here Rev Senior Agent rl -off �- od � <br />Authorized Signature Title Date <br />4- 494 -1974 Rev. 2.2002 Supersedes 4.494 -1974 Rev. 10 -1996 <br />