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11/19/2007 MON 15:31 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall 121002/004 Olio Please forward to: Nebraska Dept of Revenue 4500 Ave I PO Box 1500 Scottsbluff, NE '69363-1500 200709858 111'111111111 9907834128-0 Pgs. 1 I'IARTINEZ JUAN . Filed: 11119/2007 08,30 AM IIr NOTICE OF STATE TAX LIEN "Cobrqk. dopQrlmO<ll ~,~. PLEASE DO NOT WRITE IN THIS SPACE This Notice of State Tax Lien is issued by the Neb~ska Department of Revenue for unpaid taxes pursuant to the revenue laws of the state of Nebraska. Notice Is hereby given that taxes including penalties and interest, which are shown below, are due from the taxpayer speCified below and remain unpaid after demand. These taxes constitute a lien In the county for real and personal property belonging to the taxpayer or hereafter acaulred. . . Nebraska Identification Number Lien Filed With Social Security Number Spouse's Social Security Number 37097830 ~ Register of Deeds o County Clerk 623-50-0844 523-50-0849 Lien Serial Number Lien Type Date of Lien County . 071160121 [8] Original 0 Continuation D.corrected 11/14/2007 Hall I BUSINESS NAME AND:LOCATION ADD'RESS . TAXPAYER NAME AND MAILING ADDRESS -I Business Name Name Juan & -Martha A Martinez Street Address Street or Other Mailing Address 423 W 5th City State Zip Code City State Zip Code Grand Island NE 68801 ~ Tax -1 Cate~ory Tax Period Date of Amount of Tax Penalty Interest Adctitions Balance of N!.lmber Assessment Assessment Due 22 2003 01/01/2007 130.70 17.80 25.09 173.59 22 2004 01/01/2007 438.28 20.60 46.92 505.80 22 2005 01101/2007 349.00 17 .45 39.19 405.64 TOTAL $ 1,085.03 sign here I hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in the determinatio f 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 i extension of an effective lien, it serves to continue the priority of the slate's'interest In the affected property of the taxpayer. - . Revenue Agent /I/;'I /(J:; 308 632-1200 et' Si natur Tille Date Telephon Num r p~ Revenue Agent Supervisor Tille Da 4-494.1974 Rev. 2-2002 Supersedes 4-494-1974 Rev. 10-1995 ~ - . (}