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<br />03/19/2007 15:29 f~X 14024714429 <br /> <br />NEBRASKA Dee <br /> <br />~ 004/004 <br /> <br />200702123 <br /> <br />11111111'111 <br /> <br /> <br />_7508961-2 P1l5. <br />'BERNARD JOANNE 1 <br />Filed: 03/19/2~1 09,37 ~ <br /> <br />Please Return Original Copy to the <br />Nebraska Dept. of Revenue at 200 <br />South Silber, North Platte, NE <br />69101 <br /> <br />Q\ <br /> <br />ar. <br />lI...,.ta <br />~ <br />0;"" <br /> <br /> <br />NOTICE OF STATE TAX LIEN <br /> <br /> PLEASE DO NOT WRITE IN THIS SPACE <br />This Notice of State Tax Lien is issued by the Nebraska Department of <br />Revenue for unpaid taxes pursuaot -to -the 'rev.enue-Iaws of_the state of <br />Nebraska. Notice is hereby glve.n that taxes Including 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 />io the county for real and personal property belonging to the taxpayer <br />or hereafter acauired. <br />Nebraska Identification Number Federal Identification Number <br /> 1~972568 u " "'. '. <br /> ,- .. . <br />L;ien Serial Number Lien Filed With Social Security Number Spouse's SoCIal :Securlty:_~ur:nber <br /> 97?200302 . ~ Register of Deeds _ 0 County Clerk . - . -506-'58~342 ',;: -. 505~74-3978 <br /> . .- ,.1...' '" _," " -, - -- <br />Dale of Lien _.t' -Lien Type . _ l?~Lirit(: . -,. <br />,-' .. . ,- . :. , . .- . <br /> - - '. . ' <br />... n. o ~_ , . , , .~" o 6rigin~@ Continuatlo!j) o Corrected -..-.' -. . - .. <br /> 08t08/1997 - HALL- - -- ,-,- -" . ,. - <br /> . . <br />r. . BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND'MAlLlNG ADDRESS-"- -- '.1 <br />Business Name Name ; <br />, THOMAS D.& JOANNE L BERNARD <br />Street Address Street or Other Mailing Address <br /> 316 WEST 14TH ST <br />City State Zip Code City Slate Zip Code <br /> GRAND ISLAND NE 68801 <br />~.: Tax -I <br />Categj>ry Tax Period Date of Amount of Tax Penalty Interest Additions Balance of <br />Number Assessment AsSessment Due <br /> 22 1996 . OS/21/1997 3,773.00 188.65 106.99 '4,068.64 <br /> I <br /> i <br /> : <br /> I - <br /> I -- <br /> j <br />, . /J.ct=F ( 1m7 iogo it ) <br /> , eD . .;f q 1 ' IDftD15 <br /> ' -,- <br /> TOTAL ". . .. $-" . - 4;068.64 . ..- <br /> <br />sign .... <br />here i... <br /> <br />I' hereby certify that the Nebraska Department of Revenue has complied with the revenue Jaws of the State of Nebraska in the <br />determination of the amount shown to be due, and the taxpayer has failed to pay the amount due after demand. If this Notice of Slate <br />Tax Lie I an extension an effective lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. <br /> <br />--:- Revenue Agent 3-15-01 - 308 535-6294 <br /> <br />Pr6parer's Signa,SIJre~ =-------Title_ Date Telephone Number <br /> <br />/(-~~ g~ Revenue Supervisor --2-"7 ;--.0 ? <br /> <br />Authorized Signature Title Date <br />4-494.1974 Rev. :/..2002 Supersede. 4-494-1974 Rev, 10.1995 <br />.\ <br /> <br />