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<br />04/04/2008 FRI 14:09 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />14J002/005 <br /> <br />\)9J <br /> <br />Please forward to: <br />Nebraska Dept of Revenue <br />4500 Ave I PO Box 1500 <br />Scottsbluff, NE 69363-1500 <br /> <br />200802871 <br /> <br /> <br />STl <br /> <br /> <br />~_..m::"'l~~ <br /> <br />REVENUE <br /> <br />w_.r.v.....iIIIII.n..oa,v <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 />Revenue for unpaid taxes pursuant to. the revenue laws of the state of <br />Nebraska. Notice is l1ereby given that taxlils-including penalties and <br />Interest, which are shown belQw, 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 /> 40282759 <br />Lien Serial Number Lien Filed With tlSOCi31 Security Number Spouse's Social Security Number <br /> 72360458 [gI Register of Deeds Dcounty Clerk XXX..XXM7294 <br />Date of Lien Lien Type County <br />04/02/2008 [1g Original- 0 Continuation Dcorrected Hall <br />, . BUSINESS NAME AND L.OCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br /> Gerardo De La Cueva <br />Street Address Street ~r other Mailing Address <br /> 1414 N Piper <br />City ~une 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 2003 09/28/2006 628.00 34.65 176.24 838.89 <br />22 2004 06/10/2007 1,370.00 70.65 278.46 1.119.11 <br /> TOTAL $ 2,558.00 <br /> <br />I h~reby certIfy that the Nebraska Department of Revenue has complied With the revenue laws of the Slate of Nebraska III the deterrmnatlon of the <br />'amount shown to be. d ,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 serve continu the j~rityof the state's interest in the affeCted property of the taxpa~, <br /> <br />w ". Revenue Agent ~Ior 308 632-1200 <br />sign Pre J'!r'~nature Title Date Telephone Number <br /> <br />here'" ~(i1 0" 1J..b Revenue Senior Agent i-/ Ie 17 /"Jt)8 <br />AuthOrized Signature Title Date <br />4-494-1974 Rev. 2.2002 SuperliBde$ 4-494.1974 Rev. 10-1995 <br /> <br /> <br />~ <br />