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<br />11/30/2006 15:37 FAX 14024714429
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<br />NEBRASKA Dee
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<br />~ 002/002
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<br />Please return to:
<br />STATE OF NEBRASKA
<br />DEPARTMENT OF REVENuE
<br />1811 WEST 2ND ST STE 460
<br />GRAND ISLAND NE 68803
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<br />2006108.29
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<br />11111111I111 \
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<br />99014827&&-3 pgs: I
<br />DOMINICK scoTT E
<br />F U_; 11/301201115 10: 39 AI1 /
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<br />NOTICE OF STATE TAX LIEN
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<br />. 11.__
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<br /> : ~ PLEASE DO NOT WRITE IN THIS SPACE
<br />Th~ Notice of S~te Tax,Lie~ is Issued by thQ Nebraska Department of
<br />Revenue for unpaid taxes pursuanUo the revenue laws of the slate of
<br />Nebraska. Notice is hereby given that taxes .includhig 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 />NebraJ;ka Identification Number Federalldentificalion Number.
<br /> , 9468870 ..
<br /> '.. , ... ' . ,; . e ' .
<br />Lien Serial'Number' e'",. . .... .. , ..Lien):j!e,~ Y\!~n.:, ;"';;;"~"..!",,, ,;.,c. ..,.;,~.: ;r.l l~, ,~ef.\~t~~r.~,ri~(~Y.T~.~~'~ ;:\! i~:;; :.; .S/)?Y$~'s'~.ocl.al S~c:urity Number
<br /> . ' ~' ., I. ~~f,.. ,.,.' -:.:,.\.. "10"[.' .'~l.~t"
<br /> . i -t)~tHf ':f()(jt{C{': ;, '~:RB'giS1er"6r~~d".'~.~[Jq:qil~iYl qerl(! J~ ":.'1::'" .!506.;.92,,0076,:l."<, .;.,.; . I......~.~!\I }'1'.1'~1.,o~' L ~ r:'i' . ~
<br /> .-..-...... -... ,~ .. '~'I'" " -... .' ..." .., "'-Mn..., ......._., _.~, "_... ..~, _ ""...._, :':?'::: ',:~:;; .f: ~~~~,".l:: ..-.... -..
<br />D!l.t~, of.. Lien T Lien Type County .:1.C,.:':' ;' , \ .", I~'",.', , ~
<br />j...... ~_., .' ,~~". __I- "". h.. .. .,' I' ,'I.)-l
<br /> I!jO~i;al "'0 cci~il~~~ti~n -.'- D'c~~~ciect' ,,' .. ~ Halr...~.. ...--:.."..' "':.
<br /> i 11/25/2006 ,10' -",'_m.......' . ',.' ."~"'" . .- L.._.,~
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<br />I':' BUSINESS NAME AND LOCATION ADDRESS., '. ..~- TAXPAYER NAME .AfI!D M~I.LIJ:II~ ADp~~SS I
<br /> ....
<br />Business Name Name
<br /> , Scott E Dominick
<br /> e
<br />Street Address Street or Other Mailing Address
<br /> " 418W 4th Street
<br />city State Zip Code City State Zip Code
<br /> " Grand Islsl"!d ,. "NE 68801
<br />I TalC I
<br />Category Tax Period. Date of . Amount of Tax Penalty Interest Additions Balance of
<br />Number ASsessment " Assessment Due
<br /> 01 04/01/2006.;. 11n6/2006 8,190.00 1,638.00 263..34 10,091.34
<br /> 08/31/2006
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<br />_.,_....u.. ._........>,~, . __.___.J'.,."....._ .. .. '=.".1'. '~ r~ ' '" . " '. . < 'e
<br /> r__ r~_ , . ...... -. . ...".- .- ,'r' -~-- - , .. "-
<br /> , -....... . .~.. .~..-- . . '-- .- .. ..-... -- - .. ....." .. --....~ ., '.'- .. -- ._~._... -, ..........-- - ..~
<br /> '. ~ -.\;;;-' '.:': '1.:' _ . ',.' , . ~' ~~,.}. -. : : '. 7"1 .~ ' :,.- . I
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<br /> : I~'; j'y. L~ J I ~. \; __.....'..1-, _:i l'< " .,,;.' TOTAL' $ 10.091.34
<br />~_"_'7"""""',"I-"_ ,~.._.....,.......~.~. '._,. _... ".....d...~.~",...'..'..,.. _.... .. _ ..... __~,.~,_J'"
<br /> ".',. .. ... '_....l,... -'", ._'.~.......,~.'.-..II _...,~,._;_.,.,.. . ""J ..
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<br />I nereby certify that the Nebraska Depa,r:tnient'of Rel/enue ha,!,pOmplied with the revem,!e ;I!1IwS :ot.t~~ ~tate of Nebraska in the
<br />. F' <.. ',.delerminalion o{lhe amount shown to be due, and the taxpayer'has failed to pay the amount ,due aflerdemand.lfthis Notice of.5tate
<br />. '___H Tlv("Ueii is aii'eXt~rislbh ifal1'effective lien, it 'senies to continue the priority oflhe state'a'interest in'.the affected_prOp~'rtY'of the:iaxpay~r, '.'- . ': ". ':.
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<br />. .' ... ' ;- :. -... ,- , Revenu~ Senior Agent I / r~ 7 ).:JO~b 306 385-6073
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<br />sign Preparer's Sign u ' Title Date Telephone N~ber
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<br />here .... Revenue Supervisor lib ~d~
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<br />. ( -4-494-1974 Rev. ~e2002 Supenl8Cles 4..ol94--1a74 Rsv, 1o--~SSW
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