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02/22/2008 FRI 14:50 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall ~002/006 ~ Please forward to: Nebraska Dept of Revenue 4500 Ave I PO Box 1500 Scottsbluff, NE 69363-1500 200801453 ~etp....,~l'Ita" REVENUE _W.,__l:Iu..n..'lll_ NOTICE OF STATE TAX LIEN This Notice of State Tax Lien is issued by the Nebraska Department of Revenue-for unpaid taxes pursuant to the revenue laws ofthe.state of "'--Nebraska;'Notlce-is-'hetebt-giverrthat'taX'GtrincIUdlngpenalties'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 ae ulred. Nebraska Identification Number 99830566 LIen Serial Number Lien Filed With ~ Register of Deeds Lien Type 02/19/2008 ~Origin~1 DContinuation BUSINESS NAME AND LOCATION ADDRESS Business Name 72360251, Social Security Number Dcounty Clerk XXX-XX-7590 Spouse's Social Security Number .... - Dale- of ,Uen County DCorrected Hall TAXPAYER NAME AND MAILING ADDRESS Street Address Name Tara K Hernandez Stre.et or Other Mailing Address 247 S Plum Street City ae Zip Code City State Zip Code Grand Island NE 68801 Penalty Interest Additions Balance of Assessment Due 15.75 21.40 352.15 Tax Category Number Tax Period Date of Assessment Amount of Tax 22 2006 05/08/2007 315.00 TOTAL $ 352.15 I hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in lhe determination of the 'amount shown to 'be due and the taxpayer has failed to pay the amount due 'ilfter demand. If this Notice of State Tax Lien is an extension of an effective iien, it serves continue the priority of the state's interest in the affected property of the taxpayer. Revenue Agent T1tle Revenue Supervisor Title sign here 308 632-1200 Telephone Number 02/19/2008 Date '1-494-1974 Rev. 2-2002 SUpeol8d8l4~94-1974 Rev. 10-1995 02/19/2008 Date tL-.