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12`16/2003 09:23 FAX 14024714429 NEBRASKA UCC la 0041004 <br />STATE OF NEBRASKA <br />DE?ARTMFNT OF REVENUE <br />FIRST FEDERAL BANK BLDG <br />1811 WEST 2ND ST STE460. <br />GRAND ISLAND NE 68803 -1465 <br />011 I <br />�k. <br />dPpAtliiAlotr! <br />97itsYM111� <br />sn <br />illit <br />2 Pn <br />NOTICE OF STATE TAX LIEN <br />PLEASE 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 <br />7939248 <br />Lien Filed With <br />XQ Register of Deeds <br />[]County Clerk <br />Federal Identification Number <br />470807167 <br />Social Security Number <br />Lien Serial Nu m per <br />AL <br />L� <br />' <br />� <br />Lien Type <br />QX Original []Continuation %Corrected <br />Date of Lien <br />I 12/11120103 1 <br />County <br />Hall <br />BUSINESS NAME AND LOCATION ADDRESS <br />TAXPAYER NAME AND MAILING ADDRESS <br />Business Name <br />_ <br />Name <br />M17-Grand Islandlnc. <br />Street Address <br />Street or Other Mailing Address <br />2808 Old Fair Road, Suite K <br />City <br />State Zip Code <br />City <br />Grand Island <br />State Zip Code <br />NE 68803 <br />Tax <br />Category <br />Number <br />Tax Period <br />Date of <br />Assessment <br />Amount of Tax <br />Penalty <br />Interest <br />Additions <br />Balance of <br />Assessment Due <br />01 <br />10101/2002- 02/2812003 <br />04121/2003 <br />2,037.99 <br />340.61 <br />117.68 <br />2,496.28 <br />21 <br />07101/2003-.1 <br />09/30/2003 <br />11126131003 <br />-0- <br />13.99 <br />0.44 <br />14.43 <br />TOTAL <br />$ 2,510.71 <br />sign <br />here <br />hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in the fi <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 an extension of an effective tier, it serves to continue the priority of the state's interest in the affected property of the taxpaye X'a� <br />308 385 -6073 <br />_ Revenue Agent la I/ r <br />reparer's SigrfaturiD Title Date Telephone Num r -, <br />Revenue Senior Agent <br />orized toe Title ate <br />4.494 -1974 Rev. 2.2002 Supersedes 4.494 -1574 Rev. 70.1995 <br />