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03/23/2005 16:43 FAX 14024714429 <br />Please return to: <br />STATE OF NEBRASKA <br />DEPARTMENT OF REVENUE <br />1811 WEST 2"m ST STE 460 <br />GRAND ISLAND NE 68803 <br />NEBRASKA UCC <br />20050`2538 <br />1� 003/004 <br />RRUL. <br />03123/2005 11;12 AM <br />NOTICE OF STATE TAX LIEN <br />PLEASE <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 lien <br />in the county for real and personal property belonging to the taxpayer <br />or hereafter acquired. <br />Nebraska Identification Number Federai Identification Number <br />RITE IN THIS SPACE <br />42399793 <br />Lien Serial Number Lien Filed With SSocial ity Number Spo use's Social Security Number <br />O313� � Z Register of Deeds 0 CountyClerk -39 -0256 <br />Date of Lien Lien Type ounty <br />03718/2005 Original — - -- - - -- — <br />Ciintinuation CoHalf <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br />Raul Lopez <br />Street Address Street or Other Mailing Address <br />921 W 4th St 5 <br />City State Zip Code City State Zip Code <br />Grand Island NE 68801 <br />Tax <br />Category <br />Tax Period <br />Date of <br />Amount of Tax <br />Penalty <br />Interest <br />Addltions <br />Balance of <br />Number <br />Assessment <br />Assessment Due <br />22 12131/2000 09/17/2003 448.00 22.40 129.57 599.97 <br />22 12/31/2001 08/18/2004 359.00 17,95 71.53 448.48 <br />I I I I TOTAL I$ 1,048.45 <br />1 hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in the <br />determi ion of the amo nt shown to be due, and the taxpayer has failed to pay the amount due after demand. If this Notice of State <br />Tax Li i an extensio fan ective lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. <br />Revenue Agent (g ( 308 385 -6067 <br />sign arer's Signature Title Date Telephone Num4�, <br />here `� Revenue Supervisor 03/18/2005 <br />uthorize SJ n t r Title Date <br />