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<br />06/20/2008 FRI 14:11 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />121002/002 <br /> <br />1J <br /> <br />Please forward to: <br />Nebraska Dept of Revenue <br />4500 Ave I PO Box 1500 <br />Scottsbluff, NE 69363-1500 <br /> <br /> <br />9908563592-6 Pgs: 1 <br />KLINGINSMITH DENNETA M <br />Filed; 06/2012008 02:06 PM <br /> <br />200805344 <br /> <br />~ <br />~l7r....ka, O_I'h'no8n1:.... <br />iREVENUE <br /> <br />www....."'..n'lll....'...GDV <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 /> 42356962 <br />Uen Serial Number Lien Filed With Social Security Number Spouse's Social Security Number <br /> 72920284 00 Register of Deeds o County Clerk XXX-XX-0722 <br />Date of Lien Lien TyPE! County <br />06/18/2008 l!Ioriginal OContinUatiOn o Corrected Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br /> Denneta M Klinginsmith <br />Slreet Address Street or Other Mailing Address <br /> 1621 West Hagge Road <br />City ~tate Zip Code City State Zip Code <br /> Grand Island NE 68801 <br />Tax <br />Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of <br />Number Assessment Assessment Due <br />22 2004 08/06/2007 2,338.00 116.90 514.36 2,969.26 <br /> TOTAL $ 2,969.26 <br /> <br />I hereby certIfy that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska In the determination of the <br />amount shown to be e, 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 serv to continue the rity of the state's interest in the affected property of the taxpayer. <br /> <br />~ <br /> <br />..... <br />sign <br />here ~ <br /> <br /> <br />Revenue Agent <br />Tille <br /> <br />06/18/2008 <br />Date <br /> <br />308 632-1200 <br /> <br />Telephone Number <br /> <br />Revenue Senior Agent <br />Tille <br /> <br />06/18/2008 <br />Date <br />4-494-1974 Rev. 2-2002 Supersede$4-494-1974 Rev. 10-1995 <br /> <br />'v <br />