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09/26 -2003 15:33 FAX 14024714429 NEBRASKA UCC 1x002 /003 200312942 tr soma errs sT� Par: 1 03:40 PA NOTICE OF STATE TAX LIEN 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 specified 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. Nebraska Identification Number Lien Filed With I Social Security Number Spouse's Social Security Number 388604/4 Q Register of Deeds []County Clerk 484 -46 -8652 Amount of Tax Lien Serial Number Interest Lien Type Balance of Date of Lien County 031710026 x❑ Original []continuation 0 Corrected 09/2212003 Hall BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS Business Name Name Darrel K Fokken Street Address Street or Other Mailing Address 1425 S Harrison St City State Zip Code City State Zip Code Grand Island NAhrnAkn RRRf13 Tex Category Tax Period Date of Amount of Tax Penalty Interest Addltlons Balance of Number Assesament Assessment Due 22 I 1999 1 05/01/2003 1 1,840.36 460.09 1 600.98 j 1 2;801.43 22 1 2000 105/0112003 1 2,393.00 1 598.25 1 436.05 + 1 3,427.30 j ' I I TOTAL 1$ 6,228.73 I hereby certify 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 Notice of State (� Tax Lien is an extension of an effectl%p lien, it serves to continue the priority of the state's Interest in the affected property of the taxpayer., --r_ f/ Revenue Agent � �,�. -� 402 471 -5835 Sign pre s ' Signaturo Title Date Telephone Number ,? here Revenue Senior Agent 9 -,z -0-1 t A horized Signatur Title Date