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09/18/2003 09:04 FAX 14024714429 NEBRASKA CCC 1x002 /004 Oq V 2003U 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 specifled 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. Neoraska Identification Number 1308416 ?lone retwn to: Federal Identification Number ❑ County Clerk 47- 0526931 STATE OF NEBRASKA Lien Serial Numb r ✓� DEPARTMENT OF REVENUE Lien Type K Original . ❑Continuation ❑ Corrected 1811 WEST 2ND ST STE 460 County Hall GRAND ISLAND NE 68803 TAXPAYER NAME AND NAILING ADDRESS Business Name dti'�0tI�1i0rMt Name Quering, Inc.d /h /a Village Inn Pancake House Or r�M-0MttiR 2003U 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 specifled 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. Neoraska Identification Number 1308416 'Lien Filed With 0 Register of Deeds Federal Identification Number ❑ County Clerk 47- 0526931 Social Security Number Lien Serial Numb r ✓� Lien Type K Original . ❑Continuation ❑ Corrected Date of Lien 09116!2003 County Hall BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND NAILING ADDRESS Business Name Name Quering, Inc.d /h /a Village Inn Pancake House Street Address Street or Other Mailing Address - 2624 S Locust City State Zip Code City State Zip Code Grand Island NE 68801 Tax Category Number Tax Period Dote of Assessment Amount of Tax Penalty Interest Additions Balance of Assessment Due 01 07!0112002- 02/28/2003 05/06/2003 15,243.60 1,893.41 778.56 17,915.57 � I TOTAL $ 17,9'15.57 hereby,csrtify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in the determination of the amount shown to be due, and the taxpayer.has failed to . pay the amount due after demand, if this NoJce of State Tax Lien is an xtension of" effectl alien, It serves to continue the priority of the state's interest in the affected property of the taxpayer. Stgf Revenue Senior Agent Q lb j. 308 385 - 6073(`, Title Date Telephone Number 1 here Revenue Supervisor 7 Authorized a Tide DaA 4 -404 -1074 Ray. 2 -2002 4upwgod" 4 -404 -1074 aov. '0 -1s95