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<br />01/11/2008 FRI 15:36 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />121008/009 <br /> <br />5'-1 ;J75'Y-S-' <br /> <br />200800293 <br /> <br />Please forward to: <br />Nebraska Dept of Revenue <br />4500 Ave I PO Box 1500 <br />Scottsbluff, NE 69363-1500 <br /> <br />PAGE 2 <br /> <br /> <br />~ <br />NleIli...lIok... 0....__,,- <br />REVENUE <br /> <br />w__IWW.nu.::n..a_ <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 />~evenue for u.npaid 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 /> 3946775 <br />Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number <br /> 980100214 ~Reglster of Deeds Dcounty Clerk XXX-XX-2383 <br />Date of Lien Lien Type County <br /> 05/11/1998 o Original ~Continuation Dcorrected Hall ' <br />susaN,ESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAIUNG ADDRESS <br />Business Name Name <br /> A JANIS GUSTAFSON . <br />Street Address Street or Other Mailing Address <br /> PO BOX A <br />City ~tate Zip Code City . State Zip Code <br /> DONIPHAN NE 68832 <br />Tax <br />Category Tax Period ,Date of Amount of Tax Penalty Interest Additions Balance of <br />Number Assessment Assessment Due <br />22 1991 - 11/24/1997 2,241.00 560.25 1,000.73 3,801.98 <br /> ;1QQ";l <br /> " <br /> TOTAL $ 22,917.05 <br /> <br />I hereby certify that the Nebraska Department of Revenue has compiled wIth the revenue laws of the State of Nebr.aska in the determination of the <br />amount shown to be du and the taxpayer has failed to pay the amount due after demand. If this Notice of Stale Tax Uen is an extension of an <br />effective lien, it serves continue the p orilV of the state's Interest,in the affecled property of the taxpayer. <br /> <br />sign <br />here <br /> <br /> <br />Revenue Agent <br />Title <br /> <br />Revenue SupelVisor <br />Title <br /> <br />01/04/2008 <br />Date <br /> <br />308 632-1200 <br />Telephone Number <br /> <br />01/04/2008 <br />Date <br />4--194-1974 Rev. 2-2002 Supersedes 4-4i4-1!114 Rev. 10.1995 <br />