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<br />05/28/2008 WED 15:12 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />1210031005 <br /> <br />oi <br /> <br />Please forward to: <br />Nebraska Dept of Revepue <br />4500 Ave I PO Box 1500 <br />Scottsbluff, NE 69363-1500 <br /> <br />200804597 <br /> <br /> <br />PllS: 1 <br /> <br />, . <br /> <br /> <br />.~' <br />NlI'IiP'.",I\*, a....l'tI:IMnt ..,(- <br />REVENUE <br /> <br />_....w......"'.r..u..n...'IlI_ <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 hereby given that taxes 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 Identification Number Federal Identification Number <br /> 99473127 <br />Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number <br /> 72360450 00 Register of Deeds OCounty Clerk , XXX-XX~2275 <br />, Date of Lien Lien Type County <br /> OS/22/2008 r&lOriginal DContinuation o Corrected Hall <br />BUSINESS NAME AND LOCATION ADDRESS, TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br /> Jose F Olivera <br />Street Address Street or Other Ma!ling Address <br /> PO Box 2536 <br />City State Zip Code City Stale ZIP Code <br /> Grand Island NE 68802 <br />Tax <br />Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of, <br />Number Assessment Assessment Due <br />22 2004 06/10/2007 230.00 57.50 49.24 336.74 <br /> TOTAL $ 336.74 <br />I hereb cerl' that the Nebraska Department o. Revenue has com lied with the revenue laws of the State of Nebraska in the determination of the <br /> <br />y ify <br />amount shown to be d <br />effective lien, it serve <br /> <br />sign <br />here <br /> <br /> <br />p <br />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 />continue th priority of the state's interest in the affected property of the taxpayer. <br /> <br />Revenue Agent <br />Title <br /> <br />Revenue Supervisor <br />Title <br /> <br />OS/22/2008 <br />Date <br /> <br />308 632~1200 <br />Telephone Number <br /> <br />OS/22/2008 <br /> <br />Date <br />4-<194-1974 Rev. 2~OO2 Supersede. <1-<194-1974 Rev. 10-1995 <br /> <br />.~ <br /> <br />j <br />