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08/08/2008 FRI 14:44 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall 121002/002 o~ Please forward to: Nebraska Dept of Revenue 4500 Ave I PO Box 1500 Scottsbluff, NE 69363~1500 200806869 ..~ Nebras.ka DePiillrtmentot REVENUE www . revenue I nt: . gO\{ Notice of State Tax Lien PLEASE DO NOT WRITE IN THIS SPACE soc. SEC. NO. NEBR. IDENT. NO. SPOUSE SOC. SEC. NO. TAXABLE YEAR LIEN NO. COUNTY DATE OF NOTICE DATE OF ASSESSMENT INDIVIDUAL INCOME TAX XXXXX7309 37859773 2004 080320195 HALL 02/01/2008 11/15/2007 LUIS M ORTIZ 815 W 2ND ST GRAND ISLAND NE 68801 THIS NOTICE OF STATE TAX LIEN IS ISSUED BY THE NEBRASKA DEPARTMENT OF REVENUE FOR INDIVIDUAL INCOME TAX PURSUANT TO THE REVENUE LAWS OF THE STATE OF NEBRASKA. NOTICE IS HEREBY GIVEN THAT INDIVIDUAL INCOME TAXES INCLUDING PENALTIES AND INTEREST, WHICH ARE SHOWN BELOW ARE DUE FROM THE TAXPAYER SPECIFIED ABOVE AND REMAIN UNPAID AFTER DEMAND. THESE TAXES CONSTITUTE A LIEN IN THE COUNTY FOR PROPERTY BELONGING TO THE TAXPAYER OR HEREAFTER ACQUIRED. AMOUNT OF TAX. . . . . . . . . . . . . 214.80 PENALTY.. . . . . . . . . . . . . .. ... 10.74 INTEREST (COMPUTED TO 02/01/2008) . . 40.76 UNDERPAYMENT OF ESTIMATED TAX PENALTY 0.00 TOTAL AMOUNT DUE . . . . . . . . . .. ... 266.30 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 AMOUNT SHOWN TO BE DUE, AND THE TAXPAYER HAS FAILED TO PAY THE AMOUNT DUE AFTER DEMAND. IF THIS NOTICE OF STATE TAX LIEN IS AN EXTE ION OF AN EFFECTIVE LIEN IT SERVES TO CONTINUE THE PRIORITY OF THE ATE~S TEREST IN THE~FFECTED PROPERTY OF THE TAXPAYER. .41.. ~L;L.... .1&J/:&J11M-. .~. . .. . . f!/?l.aK .//:f;J8)f:A~-:~2fJD NP~ I ~GijkTURE TITLE DATE/TELEPHONE . .o('&rAlltlM... .~~f.fi.li4l... o./s:!~...... AUTHORIZED SIGNATURE TITLE V DATE IIT1S~