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05/10/2006 13:32 FAX 14024714429 NEBRASKA Dee 141 017 04 ' IIr l1ebraika department of reven~e DlilJIllll1111i ORELLANR CARLOS Pg" 1 Fl1Bd: 05/10/2006 10:16'AM Please Return Original Copy to the Nebraska Dept. of Revenue at 200 South Silber, North Platte, NE 69101 2,0060 415 4 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 505456896 99221004 2002 052800090 , HALL 10/07/2005 08/22/2005 CARLOS ORELLANA 304 SOUTH VINE STREET GRAND ISLAND NE 68801 THIS NOTICE OF STATE TAX LIEN IS ISSUED BY THE NEBRASKA DEPARTMENT OF REVENUE FOR INDIVIDUAL INCOME TAX PURSUANT TO 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 . . . '.' '.' . . 290.00 PENALTY ... . . . . . . . . . '. . 14~ 50' INTEREST (COMPUTED TO 10/07/2005) . 43.19 TOTAL AMOUNT DUE . . . . . . . . . 347.69 I HEREBY CERTIFY THAT THE NEBRASKA DEPARTMENT OF REVENUE HAS COMPLIED WITH THE REVENUE LAWS OF THE STATE OF NEBRASKA IN THE DETERMINATIQN 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. t.~.C .~A!J~(~~ . . . ~ER'~,~~ ATU AUTHO SIGNATURE j? /1 TY;f-,cwiVF' , , , , , . ~4.< ' TiT~~'" ..",..."... .t::L/-r!) (P /0/\ 0'" C'3' r::>; "hZ" V.-. . . . .. (,3'-'iJ~'-",~~? 1 DATE/TELEPHONE ..j.-.:;Ld... '.1''''-', ..............l..~ DATE ~ rl:'C c./ ! i() {/ 1 1IT15 10104