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12/18/2003 17:05 FAX 14024714429 NEBRASKA UCC Z002/002 <br />-0 �, <br />or <br />dbl>wMMIN <br />Ot 14wok <br />Please return to: <br />STATE OF NEBRASKA <br />DEPARTMENT OF REVENUE <br />1811 WEST 2ND ST STE 460 <br />GRAND ISLAND NE 68803 <br />s184. - u[e sr <br />99e3399913 -2 ilia: 1 <br />W-eRRND �6LgND IRC. <br />Filb .. 12 f /206'3 02:46 PR <br />200316204 <br />NOTICE OF STATE TAX LIEN <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 lion <br />in the county for real and personal property belonging to the taxpayer <br />or hereafter acquired. <br />WRITE IN THIS SPACE <br />Nebraska Identification Number <br />7939248 <br />Lleh Fled With <br />Z Register of Deeds <br />[j County Clerk <br />Federal Identification Number <br />47- 0807167 <br />Social Security Number <br />Lien Serial Number <br />&-/2 --l!V <br />� <br />Lien Type <br />❑X Original []Contlnuawn.- . []Corrected <br />Date of Lien <br />12/16/20C3 <br />County <br />Hall <br />BUSINESS NAME AND LOCATION ADDRESS <br />TAXPAYER NAME AND MAILING ADDRESS <br />Business Name <br />Name <br />W -Grand Island, Inc. <br />S:raet Address <br />Street or Other Mailing Address <br />2608 Old Fair Road, Suite K <br />City <br />State Zia Code <br />City State <br />Grand Island NE <br />Zip Code <br />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 />D 1 <br />10101/2003- <br />10/31/2003 <br />12/1612003 <br />1,045.11 <br />j <br />104.51 <br />3.61 <br />5.00 <br />1,158.23 <br />TOTAL <br />$ 1,158.23 <br />I hereby certify that the Nebraska Department of Revenue nas 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 an ten ion of n effe twe lien, it serves to continue the priority of the state's irterestt in the a:`fected property of the taxpayer. ll <br />sign Revenue Agent �t l 3D8 385 -6073 <br />g Preparer's Signatu e' Tide Date Telephon Number ; <br />here Revenue Senior Agent r <br />Au or. Si toe Title Daby <br />4- 494 -'974 Rev. 2 -2002 Supersedes 4-494 -1874 Rev. 10.1998 <br />