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01/26/2006 13: 40 FAX 14024714429 NEBRASKA Dee I4J 005/011 ~, IIr nebrasKa department of reven ue 200600726 Please Return Original Copy to the Nebraska Dept. of Revenue at 200 SOllth Silber, North Platte, NE 69101 i Notice of State Tax Lien PLEASE DO NOT WRITE IN THIS SPACE INDIVIDUAL INCOME TAX SOC. SEC. NO. ' NEBR. IDENT. NO. SPOUSE SOC. SEC. NO. TAXABLE YEAR LIEN NO. COUNTY DATE OF NOTICE DATE OF ASSESSMENT 444869292 99314290 2002 052240183 HALL 08/12/2005 06/16/2005 JUAN A HERNANDEZ JR 808 W 1ST APT 1 GRAND ISLA~ NE 68803 THIS NOTICE OF STATE TAX LIEN IS ISSUED BY THE NEBRASKA DEPARTMENT OF REVENUE FOR INDIVIDUAL INCOME TAX PURSUANT ~O THE REVENUE LAWS OF THE STATE OF NEBRASKA. NOTICE IS HEREBY GIVEN THAT INDIVIDUAL INCOME TAXES INCLUDING PENALTIES AND INTEREST, WHICH ARE SHOWN BELOW ARE DUE FROM THE TAXPAYER SPECIFIED ABOVE AND REMAIN UNPAID AFTER DEMAND. THESE TAXES CONSTITUTE A LIEN IN THE COUNTY 'FOR PROPERTY BELONGING TO THE TAXPAYER OR HEREAFTER ACQUIRED. AMOUNT OF TAX . . . . . . . . . . . 548. 00 PENALTY . . . . . . . . . . . . 27.40 INTEREST (COMPUTED TO 08/12/2005) . . . ,76.57 TOTAL AMOUNT DUE . . . . . . . . 651.97 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 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. 08~za~ PJEPARER IS SIG a-A. AU ,~..a~... TITLE ~.~,......., _~,D, IIT15 10104 J"14-:o.t;;/~J')53S:g.t.9tf DATE/TELEPHONE DATE SIGNATURE