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<br />09/09/2008 TUE 15:09 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />121002/005 <br /> <br />Please forward to: <br />Nebraska Dept of Revenue <br />4500 Ave I PO Box 1500 <br />Scottsbluff, NE 69363-1500 <br /> <br />l~lI11111! '~ll <br /> <br /> <br /> <br />PEREZ MARIO R Pss: 1 <br />Filed, 09/09/2008 10:56 RM <br /> <br />~ <br /> <br />200807770 <br /> <br /> <br />~ <br />N.,bor....k.. O...p...r1........nL..t'I" <br /> <br />REVENUE <br /> <br />.wwW.~..\t.."ullt. "".QeJ'U" <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 /> 38740427 <br />Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security Number <br /> 38740427 OORegister of Deeds o County Clerk XXX-XX~6053 <br />Date of !oien Lien Type County <br /> 09/05/2008 I!IOriginal DContinuation o Corrected Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br /> Mario R. Perez <br />Street Address Street or Other Mailing Address <br /> 816 N Wheeler <br />City state 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 04/06/2006 1,638.00 81.90 388.54 2,108.44 <br /> TOTAL $ 2,108.44 <br />I hereb certi that the Nebraska De artment of Revenue has com lied with the revenue laws of the State of Nebraska In the determination of the <br /> <br />y fy <br />amount shown to be d <br />effective lien, it serve <br /> <br />sign ... <br />here ., <br /> <br /> <br />p <br />as failed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of an <br />ity 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 />09/05/2008 <br />Date <br /> <br />308632.1200 <br />Telephone Number <br /> <br />09/05/2008 <br />Date <br />4-494-1974 Rev. 2-2002 supersedes 4-494-1974 Rev. 1lJ..1995 <br /> <br />\; <br />