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10/14/2005 16:51 FAX 14024714429 NEBRASKA Dee -~~....----~- ~ 002/004 D~ IIr nabrilska department of r&\Il!!nue 200510248 Ilrflllll(,'I-:- 9905417494-5 Pss: 1 CAVRX FLORENCIO A Fl1.d: 10/14/2005 02:28 PM Please Return Original Copy to the Nebraska Dept. of Revenue at 200 South Silber, North Platte, NE 69101' Notice of State Tax Lien PLEASE DO NOT WRITE IN THIS SPACE INDIVIDUAL INCOME TAX SOC. SEC. NO. NEBR. IDENT. NO. SPOUSE SOC. SEC. NO. TAXABLE YEAR LIEN NO. COUNTY DATE OF NOTICE DATE OF ASSESSMENT 505352562 39059553 2003 052030161 HALL 07/22/2005 06/02/2005 FLORENCIO A CAYAX 928 S LOCUST 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 . . . . . . . . . . .. 194.00 PENALTY. . . . . _ . . . . . . . 48.50 INTEREST (COMPUTED TO 07/22/2005) 14.77 TOTAL AMOUNT DUE . . . . . . .. ... 257.27 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 EXTENSION OF AN EFFECTIVE LIEN IT SERVES TO CONTINUE THE PRIORITY OF THE STATE'S INTEREST IN THE AFFECTED PROPERTY OF THE TAXPAYER. .1~/JUlW.-. ~ . . . . . . ~ ~. ..._.~......... TITLE 1[J.:I!:o.~. 6?)535~f.29~ DATE/TELEPHONE . . . ~-((:--c?J~. . . . . DATE ?l) /lT1 ~ 10/04