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<br />01/11/2008 FRI 15:35 <br /> <br />FAX 402 471 4429 UCC SECRETARY OF STATE ......... 2a008 0 0 2 91 <br /> <br />1dI004/009 <br /> <br />NIi Sn 'Of St..t. Joh" II 0..1. . UCC iTL <br /> <br />&> <br /> <br /> <br />Please forward to: <br />Nebraska Dept of Revenue <br />4500 Ave I PO Box 1500 <br />Scottsbluff, NE 69363-1500 <br /> <br />9908542742-0 PIl': 1 <br />DOMBROWSKI ROBERT L DEC'D <br />Filed: 01/11/2008.02:36 PM <br /> <br /> <br />~e<p.."':;m; 01' <br />. REVENUE <br /> <br />w_...,...IlI......n..QDtM' <br /> <br />NOTICE OF STATE TAX LIEN <br /> <br /> . PLEASE 00 NOT WR~TE 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 realand personal property belonging to.the taxpayer <br />or hereafter acquired. . <br />Nebraska Identification Number Federal Identification Number <br /> 16245261 <br />Lien Serial Number. Lien Filed With Social Security Number Spouse's Social Security Number <br /> 32550515 00 Register of Deeds Dcounty Clerk .. XXX~XX-2254 XXX~XX-8180 <br />Dat~ ofLien Ljen Type County <br />01/09/2008 00 Original Dcontlnuatlon DcorreCted Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Bu~.iness Name Name <br /> Robert L Dec'd & Deborah 0 Dombrowski . "-. <br />Street Address Street or Other Mailing Address <br /> 422 N White <br />City ::itate Zip Code City State Zip Code <br /> Grand Island NE 68803 <br />Tax . <br />Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of <br />Number Assessment Assessment Due <br />22 2002 07/14/2005 100.69 27.90 144.23 272.82 <br />22 2003 06/t9/2007 133.00 6.65 32.54 172.19 <br />22 2004 05/3112007 141.00 7.05 26.04 174.09 <br /> TOTAL $ 619.10 <br />I hereb certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in the determination of the <br /> <br />y <br />amount shown to be d <br />eff8ctivelien. it seN <br /> <br />sign <br />. here <br /> <br /> <br />and the taxpayer has failed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of an <br />o conti"ethe r!ority of the. state's interest in the affected property ofthe taxpayer. <br /> <br />*_ Revenue Agent 01/09/2008 308632-1200 <br />- nature Title Date . Telephone Number <br /> <br />Revenue Supervisor <br />Title <br /> <br />01/0912008 <br />Date <br />.....94-197.. R"v. 2-2002 SupBrlllld"......S4-197.. Rev. 10-1995 <br /> <br />\L. <br />