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<br />01/25/2008 FRI 15:16 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall
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<br />1iI002/003
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<br />NI! Sse; af S......e .Jlllhn ft (1.'_ - ucc sn.
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<br />Please return to:
<br />StATE OF NEBRASKA
<br />DEPARTMENT OF REVENUE
<br />1811 WEST 2ND ST SIE460
<br />GRAND ISLAND NE 68803
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<br />99 p:
<br />I'\Ul..l..INS-I'IOSTEK KIm3ERLY J
<br />Filed: ,01/25/2008 02:34 Pl'I
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<br />200800642
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<br />1II.b-r...k., D~r1"""M 011
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<br />REVENUE
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<br />'W1j/f'w..........n..........$..l)CiI\l'
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<br />NOTICE OF STATE lAX LIEN
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<br />PLEASE 00 NOT WRITE IN THIS SPACE
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<br />This Notice of State Tax Lien is issued by the Nebraska Department of
<br />Revenue for unpaid taxes pursuant to the revenue laws of the 'state of
<br />Nebraska. Notice is hereby given thattaxes including penalties and
<br />interest, which are shown below, are due from the taxpayer specified
<br />below and remain unpaid after demand. These taxes constitute a lien
<br />In the county for real and personal property belonging to the taxpayer
<br />or hereafter acquired. ,"
<br />Nebraska Iden.tlflcatlon ~urnber
<br />8991022
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<br />.. ::'~: ;:'
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<br />Federal Identification Number'
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<br />Lien Serial Number '" ,', : R,negF, ~":,:,:,e, :",o:,::",eed,s, ' ,,"0' County, Clerk,'" I~ 5,: O~,',,'al 5,;;, ",rI~~",~;~,,7,r3 Spouse's Social Secunty Number
<br />~";'oJIQjlo'v';'~,<f',' ~ ',' tL .""
<br />,pa~~o!,l.lliln' ;,' , Lie~Type, : ,',', ' " "Cou,nty '" ,'"
<br />, 01/23/2008 : " r&10rlginal 'DContiriu~tion o Corrected , 'HaH '''" ,,'
<br />_... , . BUSINES$ NAME. AND, LOCATION, A,QPRESS " TAXPAYER, NAME AND MAlLlNC3 ADI?RESS
<br />. Business Name ' Name
<br />Kimberly J Mullins-Mostek,
<br />Street or other Mailing Address
<br />3618 Palamino Drive
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<br />Street Address
<br />City state Zip Code
<br />Tax
<br />Category Tax Period Date of Amount of Tax
<br />Number Assessment
<br />01 01',-01/2007- 1 0/171200.7 891.75
<br />07/16/2007
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<br />City State
<br /> Grand Island NE
<br /> Penalty Interest . Addltlon.s
<br />; 163~35 42.29
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<br />'ZipCode
<br />68803
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<br />Balance of
<br />Assessment Due ,','
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<br />. 1,097.39
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<br />TOTAL'
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<br />$
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<br />1,097.39' '-
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<br />'.hereby, certify that the Nebraska Department of Reyenue has complied with the revenue laws oUhe State of Nebraska in the lfeter!nination of the
<br />-~moiJnt shOwn to be due: 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 />. effective lien, it selVes to continue the priority oUtie state's interest in the affected property of the taxpayer'; " ;
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<br />:,-.', .... ~ ~~~ k) , , Revenue Senior Agent 01/23/2008
<br />sign ~er's 81 na re .' Title' Date
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<br />here .... .' Revenue Supervisor
<br />Autho . Title
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<br />308 '385-6073 . '.
<br />Telephone Number
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<br />01/23/2008
<br />Date
<br />4-494-1974 Rev. 2.2002 Supemldes 4-494-1974 ROl't. 10-1995
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