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141 003/003 12/19/2005 17:21 FAX 14024714429 NEBRASKA Dee 200512362 IIlrlllllll'1 : 9905427&14-7 PGlI,1-! DENTON JERRY L. Filed: 12/19'2005 03:07 PM \)~ Please Return Original Copy to the Nebraska Dept. of Revenue at 200 South Silber, North Platte NE , 69101 ar ~~ "*,moM Qf~ NOTICE OF STATE TAX LIEN PLEASE DO NOT WRITE IN THIS SPACE This Notice of State Tax L.ien is issue~ by the Nebraska Department of Revenue fol' unpaid taxes pursuant toithe raven'ue 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 deman:d. These taxes constitute a lien in the county for real and personal prbperty belonging to the taxpayer or hereafter acquired. Nebraska Identification Number , Federal Identification Number /~11.p10905 , Lien Serial Number Lien Filed With Social Security .(\jumber Spouse's Social Security Number , .' 50490021- lKl RegIster of Deeds o County Clerk 505-52~301 0 ' 508-54-8592 " Date of Lien Lien Type .County, , " I 0 - o Corrected 12/16/2005 I!l cpriginal Continuation HALL:' .,- . I BUSINESS NAME AND LOCATION ~DDRESS TAXPAYER NAME AND MAILING ADDRESS -I Business Name Name JERRY L. & CAROLE L. DENTON Street Address i Street or Other Mailing Address 205 S CEDAR . City State Zip Code City State Zip Code GRAND ISLAND NE 68801 r Tax I 1 Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of, Number Assessment Assessment Due ! 22 12/01/2004 I 4,402.00 220.10 442.12 5,064.22 2003 ! , TOTAL $ 5,064.22 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 L;~ .Is~:e"~ ~ ~~ . ...... to ",n'"e the p'O<ilY of !he ,tale, 'ree...' In the affected P....rty of thelaXPaye'. . . ... r/.4d1- G..~ Revenue Agent /c:l-lt-tJ5 - - -", ,308 535~8294 sign Pre a r's Slgnatu Tille Date Telephone Number here .... Revenue Senior Agent ) J. -/" -OS- Tille Date 4-494-1974 Rev. 2-2002 $uporsede. 4-494.1974 Rev. 10.199G { r