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05/28/2008 WED 15:12 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall ~002/005 (jl HE SgC gf Sto,'. Jgnn II Goo'g - ute ST~ Please forward to: Nebraska Dept of Revenue 4500 Ave I PO Box 1500 Scottsbluff, NE 69363-1500 9908561235-8 Pes: 1 CORTEZ CRUZ MATIAS Filed, OS/28/2008 09,12 AM 200804596 ~. N...ln.su. 081POIlr1Jm;OM 01 REVENUE _..._....iI'."'UIlll_n...._ . NOTICE OF STATE TAX LIEN PLEASE DO NOT WRITE IN THIS SPACE This Notice of State Tax Lien is issued by the Nebraska Department of Revenue for unpaid taxes pursuant to the revenue laws of the state of Nebraska. No.tice is hereby given that taxes including penalties ~hd. 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 acquired. Nebraska Identification Number Federal Identification Number 99299291 Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number 72010202 I!IRegister of Deeds Dcounty Clerk XXX-XX-4280 Date of Lien Lien Type County OS/23/2008 1!I0riglnal DContinuation o Corrected Hall BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS Business Name Name Cruz Matias Cortez Street Address Street or Other Mailing Address 2218 N Park Avenue City ~tate Zip Code City State . Zip Code Grand Island NE 68803 Tax Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of Number Assessment Assessment Due 22 2005 05/01/2007 157.97 11.25 31.60 200.82 TOTAL $ 200.82 I hereby certify that the Nebraska Department of Revenue has complied WIth the revenue laws of the State of Nebraska In the deterrmnation of the amount shown to be du ,and the taxpayer has failed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of an effective lien, it serve continue the rio/ity of the state's interest In the affected property of the taxpayer. Revenue Agent OS/23/2008 Title Date Revenue Supervisor Title sign here 308 632-1200 Telephone Number OS/23/2008 Date """94-197" Rev. 2-2002 Super$edes """94-1914 RllV. 10-1995 .0]