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02/01/2006 15:53 FAX 14024714429 NEBRAS~A Dee ~005 D\ 200600909 IIr N~-G)-F';tJS+. TE TAX LIEN UcL~ q-uoctS ' No. qry - l'-O~cr. -, MllrD~I';D d1i~r:1len; uh,c,v.<VII,\i 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 39467554 Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number 972410170 [gJ Register of Deeds D County Clerk 550.61-2566 Date of Lien Lien Type County 08/29/1997 o Original lKJ Continuation o Corrected HALL I BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS 1 Business Name Name DALE A HENRICKSON Street Address Street or Other Mailing Address 5420 FRUITVALE RD City State Zip Code City State Zip Code NEWCASTLE CA 95658 I Tax \ Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of Number Assessment Assessment Due 22 1992 07/15/1997 236.00 59.00 84.85 379.85 TOTAL $ 379.85 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 effectiv,e lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. 402 471-5928 REVENUE AGENT Title l-l", -0 (0 Date sign .. here ... REVENUE SENIOR AGENT Title Telephone Number / _ .ztr .::J c.- Oate f\\ 4-494~1974 Rev_ 2-2002 Supersede. 4-494-1974 Rev, 10-1995 ~~ I '