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12/19/2005 17:21 FAX 14024714429 NEBRASKA Dee 141 0021003 -~~--_..~---_.....---...-...,-~~- 2005123-63 \1111111111 _ 990'427812-3 PIS: 1 MENCIA CRIST08AL R, Filed: 12/19/2005 03:07 ~ Please Return Original Copy to tbe Nebraska Dept. of Revenue at 200 South Silber; North Platte, NE 69101 ~~ \J, Ir NOTICE OF STATE TAX LIEN ~liJ, CIOP-l1m'CII t:Ii'-MtJl;it , 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 42035368 Lien Serial Number Lien Filed With Social Security Number spouse's Social Security Number ~ Register of Deeds o County Clerk ., ., 52240488 505-41-0137 ' ' 918-71-6688 Date of Lien Lien Type county _ '_..10_ , - 12/16/2005 129 Original 0 Continuation o corrected'_ HALL .,.i " " 0>' - - I BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS 1 Business Name Name CRISTOBAL R. & MAIRA MENCIA Street Address J Street or ,Other Mailing Address 706 HEDDE 5T APT 9 City State Zip Code City . State Zip Code GRAND ISLAND ' NE 68801 r Tax 1 Category Tax period Date of Amount of Tax Penalty Interest Additions Balance of Number Assessment Assessment Due 22 2001 10/12/2004 280.00 14.00 67.71 361.71 22 2002 06/21/2005 409.00 20.45 60.50 489.95 - ,- ,,- TOTAL $ 851.66 sign ... here ... \ 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 State Tax Lien.i an extension of an eff~tive lien, it serves to continue the priority of the state's iniarest in the affected property of the taxpayer. Revenue Agent 1:;'-1 {If"'O b 308 535-8294 Title Date Telephone Number Revenue Senior AQent / J.. ....16 ,-()~ Title Date 4-'194-1974 R.ov, 2-2002 Sup.r.odes 4-494-1974 ROil, 1M995 f. V