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<br />06/12/2007 TUE 15:23 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />121005/005 <br /> <br />200704892 <br /> <br />Illllllllnll r <br /> <br />9907513184-9 Pas: 1 <br />BOSTWICK JESSE 0 <br />Filed: 06/12/2007 12:58 PM <br /> <br />o'h <br /> <br />Please Return Original Copy to the <br />Nebraska Dept. of Revenue at 200 <br />South Silber, North Platte, NE <br />6910 I <br /> <br />. <br />llolll'Uklo ' <br />deplitmet\l <br />~.~ <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 pursuant to the revenue laws of the state of <br />Nebraska. Notice is hereby given 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 />In the county for real and personal property belonging to the taxpayer <br />or hereafter acquired. <br />Nebraska Identification Number Federal Identification Number <br /> 12619817 <br />Uen Serial Number Lien Filed With Social SecuritY Number 'Spouse's Social Security Number <br /> 60410178 ' [!l Register of Deeds o County Clerk 506-44-2023 <br />Date of Lien Lien Type County <br /> 06/08/2007 [g] Original D Continuation D Corrected HALL <br /> BUSINESS NAME AND LOCATION ADDRESS " TAXPAYER NAME AND MAILING ADDRESS I <br />BusinessName 'Name <br /> JESSE 0 BOSTWICK <br />Street Address Streel or Other Mailing Address <br /> 238 SOUTH OAK <br />Cily State Zip Code City State Zip Code <br /> GRAND ISLAND NE 68801 <br />Tax I <br />Category Tax Period Date of Amount of Tax , Penalty Interest Additions Balance of <br />Number Assessment Assessment Due <br />22 2003 11/18/2005 239.00 190.25 67.92 497.17 <br />22 2004 11/16/2005 0.00 256.25 32.69 288.94 <br />22 2005 10/15/2006 0.00 0.00 28.40 28.40 <br />22 2006 03/14/2007 0.00 40.79 0.00 40.79 <br /> TOTAL $ 855.30 <br /> <br />I hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the Slate of Nebraska in the <br />determination of the amount shown to be due, and the taxpayer has failed to pay lhe amount due after demand. If this Notice of Slate <br />Tax Lien is an extension of an tffective lien, it serves to continue the priority of the state's I,nteresl in the affected property of the taxpayer. <br /> <br />- Z R~venue Agent t - ,f -0 7 ' 308 535-8294 <br /> <br />Tille Date Telephone Number <br /> <br />Revenue Senior Agent h -B-t)] <br /> <br />Tille Dale <br />4-494-1974 Rev. 2.2002 Sup8lades 4-494.1974 Rev, 10-1995 <br /> <br /> <br />sign ... <br />l1ere .. <br /> <br />v <br />