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<br />07/16/2008 WED 15:19 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />1210021002 <br /> <br />& <br /> <br />Please forward to: <br />Nebraska Dept of Revenue <br />4500 Ave I PO Box 1500 <br />Scottsbluff, NE 69363-1500 <br /> <br />Ilrnll'lnr~ .n <br />'~_3 I"~ ~ <br /> <br /> <br />FRIESEN TODD W Pas: 1 <br />Filed, 07/16/2008 09:42 AM <br /> <br />200806145 <br /> <br /> <br />~ <br />Niear"lIIh, DftIlollnnlieM eM' <br />REVENUE <br /> <br />WWW.r......lIiU..fi._...Cl..... <br /> <br />NOTICE OF STATE TAX LIEN <br /> <br />PLEASE DO NOT WRITE IN THIS SPACE <br /> <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 ~he 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 /> <br />30102774 <br /> <br />Lien Serial Number <br /> <br />Lien Filed With <br /> <br />00 Register of Deeds <br /> <br />Lien Type <br />.07/11/2.0.08 OOOrlglnal DContinuation <br /> <br />BUSINESS NAME AND LOCATION ADDRESS <br />Business Name <br /> <br />8.067.0137 <br /> <br />Social Security Number <br />DCounty Clerk XXX-XX-6717 <br /> <br />Spouse's Social Security Number <br />XXX-XX-9294 <br /> <br />Date of Lien <br /> <br />County <br />o Corrected Hall <br /> <br />TAXPAYER NAME AND MAILING ADDRESS <br /> <br />Street Address <br />City t;tate Zip Code <br />Tax <br />Category Tax Period Date of Amount of Tax <br />Number Assessment <br />22 2.0.06 11/21/2.0.07 11,515.0.0 <br /> <br />Name <br />Todd W & Lori Friesen <br />Street or Other Mailing Address <br />4134 W Faidley Avenue <br /> <br />City state Zip Code <br />Grand Island NE 68803 <br />Penalty Interest Additions Balance of <br /> Assessment Due <br />575.75 1,143.3.0 13,234..05 <br /> <br />TOTAL <br /> <br />$ <br /> <br />13,234..05 <br /> <br />I hereby certify that the ~raska Department of Revenue has complied with the revenue laws of the State of Nebraska in the determination of the <br />amount shown to be dl(9Isnd the taxpaYE}I)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~ contin., the prifiiity of the state's interest in the affected property of the taxpayer. <br /> <br />. .. r /GJ'......../u...- Arh)'1 Revenue Agent 07/11/2.0.08 3.08632-12.00 <br />sign P~s ~ure , /' Title Date Telephone Number <br /> <br />here ~ {;7l-bd YL" /;../; Revenue Senior Agent 07/11/2.0.08 <br />Authorized Signature Tille Date <br />4-494-1974 Rev. 2-2002 Supers._ 4-49-4-197<4 Rev. 10-1995 <br /> <br />v <br />