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11/08/2005 16:59 FAX 14024714429 NEBRASKA Dee @004/005 vCb 9905421872-7 Plilli: 1 KLINGINS"ITH DENNETA M F11.d: 11/07/2005 11:47 AM >'1'1!'lase retUrn to: STAlE OF NEBRASKA DEPARTMENT OF REVENUE 1811 WEST 2ND ST STE 460 GRAND ISLAND NE 68803. 200511104 ar NOTICE OF STATE TAX LIEN 1i\ObI1it"* d*....'1il1~ Of~ 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 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 Federal Identification Number 9141480 Lien Serial Number D~J IY:f3.4:~ :, '" . Date of Lien , ,. '; ,'.. . :. 1'1/63i200~'. . '.' Lien Filed With ':~ Register of De~ds 0 County Clerk Lien Type . '06riginal 0 Contin,uation Social Security Number 506-12-0722 Spouse's Social Security Number o Corrected County Hall I BUSINESS NAME AND LOCATION ADDRESS Business Name TAXPAYER--NAME AND MAILING ADDRESS r Street Address Name Denneta M Klinginsmith Street or Other Mailing Address 1621 W Hagge City State Zip Code Grand Island NE 68801 Penalty Interest Additions Balance of I Assessment Due 59.20 3.79 654.97 62.17 0.92 684.80 75.00 13.61 368.61 City State Zip Code r Tax Category Tax Period Date of Amount QfTax Number Assessment 01 08/01/2005- 11/03/2005 591.98 06/31/2005 01 09/01/2005- 11/03/2005 621.71 09/30/2005 21 01/01/2004- 07/30/2005 300.00 12/31/2004 TOTAL .$ 1,728.38 I hereby certify that the Nebraska Department of Revenue has complied with the revenue- laws of the State of Nebraska in the determinaiion of the amount shown to be due, and the taxpayer has failed 10 pay the amount due after demand. If this Notice of State Tax Lien is an extension of an effective lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. V Revenue Senior Agent 11) " )~~ 308 385-6073 Title Date Telephone Number Revenue Supervisor Title 11/04/2005 Date A..<l94-1974 Rev. 2-2002 Supe",edes 4-494-1974 Rev. 10-1995 ~L sign ... here ..