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<br />04/25/2007 WED 15:41 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />121002/002 <br /> <br />o~ <br /> <br /> <br />9907506856-5 Pss: 1 <br />ROSS ROBIN L. <br />Filed: 04/25/2007 09:36 AM <br /> <br />200703343 <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 />Ir <br /> <br /> <br />NOTICE OF STATE TAX LIEN <br /> <br />l\Ob'l$~ <br />dGjlecbMDI <br />of ftV4l\.tlt <br /> <br /> PLEASE DO NOT WRITE IN THIS SPACE <br />This Notice of State Tax Lien is issued by the Nebraska Department of <br />Rev.enuefor unpaid taxes pursuant to the revenue laws of the state of <br />Nebraska.. Notice is hereby given that taxes including p~nalties 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 />Nebraska Identification Number Federalldentfficatlon Number <br /> 19478550 <br />Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number <br /> 62230085 ~ ReQister of Deeds D County Clerk 505-78-9922 <br />Date of Lien . . Lien Type - County <br /> 04/2312007 [gJ Original 0 Continuation o Corrected HALL <br />r BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name. <br /> ROBIN L. ROSS <br />Street Address Street or Other M'!liling Address <br /> 904 W 10TH ST <br />City State Zip Code City State- Zip Code <br /> GRAND ISLAND NE 68801 <br />I Tax <br />Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of <br />Number Assessment Assessment Due <br />22 2004 OS/25/2006 189.00 9.85 25.10 223.95 <br /> TOTAL $ 223.95 <br /> <br />/ <br /> <br />sign ... <br />here ... <br /> <br />I hereby certify that the Nebraska Department of Revenue has complied with the revenue laws 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 State <br />Tax Lien' an extension of an e1fc,c:fve lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer. . <br /> <br />-. Revenue Agent 4-2-3 ;0'1 308 535-8294 <br /> <br />arer's Title Date Telephone Number <br /> <br />Revenue Supervisor -9"'-fJ)'-"() 7 <br />Title Date <br />4-49-4.1974 Rev. 2.2002 SllPtrsede$ ..-49-4.1974 Rev. 11)..1995 <br /> <br /> <br />t <br />