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<br />04/21/2008 MON 14:43 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall
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<br />1210021005
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<br />HI Sue lOt" ~t.t" John II G"l" - ue:e: STl.
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<br />. Please forward to:
<br />Nebraska Dept of Revenue
<br />4500 Ave I PO Box 1500
<br />Scottsbluff, NE 69363-1500
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<br />200803352
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<br />9908556772-9 Pgs: 1
<br />GARCIA ROSA JOSE M
<br />Fll.d: 04/21/200811:55 AM
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<br />Nll!IlIl....k., Dep...._oI
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<br />REVENUE
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<br />NOTICE OF STATE TAX LIEN
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<br /> PLEASE DO NOT WRITE IN TH.IS 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. Notlce.is hereby ,given ,that taxes Including penalties and
<br />fnterest, which are shown below, are due from the taxpayer specified
<br />below ~nd 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 /> 98853244
<br />Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number
<br /> 72360433 00 Register of Deeds Dcounty Clerk XX'><:..XX-3037
<br />Date Of, lien Lien Type' County
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<br /> 04/18/2008 '.. 00 Original Dcontlnu~tion o Corrected Hall
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<br />I BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS
<br />Business Name Name
<br /> Jose M Garcia Rosa
<br />Street Address Street or Other Mailing Address
<br /> 212 E 8th Street
<br />City ::itate Zip Code City State Zip Code
<br /> Grand .Island . NE 68601
<br /> Tax
<br />Category Tax Period Date of Amount ofTax Penalty Interest Additions Balance of
<br />Number Assessment Assessment Due
<br /> 22 2004 09/27/20Q7 1,002.00 50.10 207.04 1,259.14
<br />_,,~,,"...." .22:.;....... ... ... -2005 .......n... _.Qg!Q~J~_QQZ,", 1 293.00 64.65 . 189.60 1,547.25
<br /> '-'''-.",'-,''- ."...,...,.I_".~._:,-,-~~.._-,-.-~-..,-,-..- .,._....._.~..""'...,._."._,.."'..,~.,_~..'_._'~r'. .,~,._,~'~.""~r.'_...,_,u,_,_._..,... ,..-~..... ,...... ,~......,-.,....,...~.
<br />,..,._,-...-".. ...~,..., ...".......,.~,,,.,~..,...~~,.,",._,..,-.._...,....-.....,.... ,.."....-.
<br /> 22 2006 05/04/2007 1 04.00 5.20 8.41 117.61
<br /> TOTAL $ 2,924.00
<br />I hereb certi that the Nebraska De artment of Revenue has com lied with the revenue laws of the State of Nebraska in the determination of the
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<br />y fy p, , p
<br />amount shown to be du . and the taxpayer has failed to pay the amount due after demand. If this Notice of State Tax Uen is an extension of an
<br />effective lien, it serve continue the .orjty of the state's interest in the affected property of the tax~,er.
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<br />Revenue Agent t/ ~tf'
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<br />here Revenue Supervisor
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