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01/11/2008 FRI 15:35 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ aa1200800293 1dI007/009 .IJIIIIIIIII~ 9908542754-5 P . GYSTAFSON A JANIS QS. 1 . F~led, 01/11/2009 02:50 PM an Please forward to: Nebraska Dept of Revenue 4500 Ave I PO Box 1500 Scottsbluff,NE 69363-1500 ~ N.br.....k... D....fIb:rHom: ~ REVENUE ....._.t.,;'.nu..n..QDI'If. ~- '-"-'~"",-, (Q~ 9 ~ __~~_Y~7 r;-~ NOTICE OF STATE TAX LIEN ,--""'........~- .~-~ PLEASE DO NOT WRITE IN THIS SPACE This Notice of State Tax Lien is issued by the Nebraska 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 aCQuired. Nebraska Identification Number I Federal Identification Number 3946775 Lien Serial Number Lien Filed With. Social Security Number Spouse's Social Security Number 980100214 ~Regi$ter of Deeds Dcounty Clerk XXX~XX-2383 Date of Lien Lien Type County 05/11/1998 OOriginal ~Continuation o Corrected Hall BUSINESS' ,NAME .AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS Business Name Name A JANIS GUSTAFSON Street Address Street or other Mailing Address PO BOX A City :state Zip code City State lip Code . DONIPHAN NE 68832 . Tax Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance Of Number Assessment Assessment Due , 22 1986 11/24/1997 717.25 179.31 891.57 1,788.13 22 1987 11/24/1997 1,021.00 255.25 1,,125.82 2,402.07 22 1988 11/24/1997 1,496.00 374.00 1,439.56 3,309.56 22 1989 11/24/1997 4,767.64 -1,191.94 3,922.14 9,881.72 22 1990 11/24/1997 897.00 224.25 612.34 . 1,733.59 TOTAL $:; See :i?;ge 2 Iherebcerti that the Nebraska De artment of Revenue has com lied with the revenue laws of the State of Nebraska In the determination of the y fy p p . amount shown to be d . and the taxpayer has failed to pay the amount 4ue after demand. If this Notice of State Tax Lien is an extension of IiIn effective lien, it serve 0 contln sign here Revenue Agent Title Revenue Supervisor Title 01/04/2008 Date 308 632-1200 Telephone Number 01/04/2008 Date 4-494-1974 Rev. 2.2002 Superadlls 4-494-1974 Rev. 10-1995 SEE ATTACHMENTS {j..-.