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03/10/2006 16:38 FAX 14024714429 NEBRASKA Dee III 005/007 J~ 200'602147 9906442709-5 Pss: 1 LEWIS JAHES A. Filyd; 03/10/2006 12:41 PM Please Return Original Copy to the Nebraska Dept. of Revenue at 200 South Silber, North Platte, NE 69101 Ir NOTICE OF STATE TAX LIEN l.'ICI)~ dolWlnMol'il or. WI'4Jl.' PLEASE DO NOT WRITE IN THIS SPACE Thi.s 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 shawn below, are due from the taxpayer specified below and remain unpaid after demand. These taxes constitute.8 lien In the county for real and personal property belonging to the taxpayer or hereafter acquired. Nebraska Identification Number Federal Identification Number - . 98791001 Lien Se!ial Number' Lien Filed With Social Security Number ~pp,l!s.~'.s~oclallSec.iJrity Number .. -. ,.- , -,52241422 . - ~ ~egi.ster:9H)e~?s o County Clerk 567-45-7656 -, -- '. ~:: , . to < .' , " ., . Date of Lien . Lien Type - - -- County " '~"';~" , .". ."" . ,. ...'" .. .. _ 03/07/2006 l~lOrI9in~1 0 Continuation o Corrected; . _ .'. HALL: .~ ..... :: ~,I - v" ~ .",,- .~,- , ." h_." ''''-" " ,-- '-'". ' '"' I- I BUSINESS NAME AND L,OCATION ADDRESS TAxPAYER NAME AND MAILING ADDRESS I Business Name Name ,. JAMES A. LEWIS Street Address Street or Other Mailing Address 107 SOAK ST APT 2 City State Zip Code City State Zip Code GRAND ISLAND NE 6B801 ' I Tax I Category Tax Period Date of Amount of Tax Penalty Interest Additions Baiance of Number Assessment Assessment Due 22 2003 OS/25/200~ 1B6.00 46.50 21.16 253.66 22 2004 OS/25/2005 335.00 26.75 17.95 379.70 .. -;' ,- ,. : -, -, ~ -.j"- TOTAL $ 633.36 I hereby certify t~at 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' ,an extension 0 n effective lien, it serves to continue the priority of the state's interest in the affected' property of the taxpayer. " _ ~ - Revenue Agent ,,-1":1-Ofa 30B 535-8294 Title Date Telephone Number Revenue Supervisor Da~e?"" l-a6 r0- Title 4--494-1974 Rev. 2.-2002. SupersAdu-'l--'194-1974 Rev. 10.1995 '--:'.__ . sign .. here ..