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12/02/2005 16:13 FAX 14024714429 NEBRASKA Dee 141 002/003 200511899 II TllI"lIlll 99054241541-5 Pi/Ii' 1 PETERSON ROLRND Fil.d, 11/29/2005 11,59 AM Please Return Original Copy to the Nebraska Dept. of Revenue at 200 South Silber, North Platte, NE 69101 ) ~ Q ar Il/llms!llo CIOlIOi1monl 0( ..... NOTICE OF STATE TAX LIEN This Notice of State Tax Lien is issued by the Nebraska Department of , ' Revenue for unpaid taxes pursuant_ to the rev.enUG 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 Federalldentiflcatlon Number PLEASE DO NOT WRITE IN THIS SPACE 44096380 Lien Serial Number Lien Filed With 51960201' , IKlRegiste~ of Deeds D County Clerk Date of, Lien ,..",: - ' Lien Type, ',' : 11/22/2005 ' IEloriglnal' D Conti-nuation I BUSINESS NAME AND LOCATION ADDRESS Business Name Social Securily Number _ 513-34.5540 Spouse's Social,~e~uriIY,N~mber 'c:_oun~,_:" _' D Corrected ' HALL TAXPAYER NAME AND'MAlLlNG ADDRESS I Street Address City I Tax Category Tax Period Number 22 1999 22 2000 22 2001 Name ROLAND PETERSON Street or Other Mailing Address PO BOX 741 State Zip Code City State Zip Code GRAND ISLAND NE 68802 Date of Amount of Tax Penalty Interest Additions Balance of I Assessment Assessment Due 03/16/2005 3,122.00 780.50 1,304.56 5,207.06 03/16/2005 3.113.00 778.25 1,020.63 4,911.88 03/16/2005 5,900.13 1,475.03 1,403.42 8,778.58 TOTAL "'_d $ 18,897.52 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 Slate Tax Lien' an extension of an effective lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. , [ ~ / r 2Z.-05' 308 535-8294 sign .. Date Telephons Number here ... '1/~,;l:;-c:'S Date P.D ' 4-494-1974 Rev. 2-2002 Supersede. 4-494-1974 Rev. 10.1995 \..