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<br />NEBRASKA Dee <br /> <br />~ 004/004 <br /> <br />10/14/2005 16:52 FAX 14024714429 <br /> <br />66 <br /> <br />ullnlllrll~11 <br /> <br />9905411497-1 pgs: 1 <br />LOPEZ AUGUSTINE <br />Filed: 10/14/2005 02:28 PM <br /> <br />I -- <br />I <br /> <br />200510250 <br /> <br />Please Return Original Copy to the <br />Nebraska Dept. of Revenue at 200 <br />South Silber, North Platte, NE <br />69101 <br /> <br />Ir <br /> <br />NOTICE OF STATE TAX LIEN <br /> <br />1I_rCl. <br />.iHlllmoM' <br />ot~, <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 /> 41384326 <br />Lien Serial Number Lien Flied With Social Security Number Spouse's Social Security Number <br /> 40090104 ~ Register of Deeds o County Clerk 465-25-6836 <br />Date of Lien Lien Type County <br /> 10/12/2005 ~ Original D Continuation D Corrected HALL <br />I BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS I <br />Business Name Name <br /> AUGUSTINE LOPEZ <br />Street Address Street or Other Mailing Address <br /> 8309 TALBOT ST APT 1-N <br />City State Zip Code City State Zip Code <br /> KEW GARDENS NY 7909 <br />I Tax I <br />Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of <br />Number Assessment Assessment Due <br />22 2000 11/04/2003 1,351.00 69.20 436.98 1,857.18 <br /> " . <br /> TOTAL $ 1,857.18 <br /> <br />I hereby certify that the Nebraska Department of Revenue has complied with the revenue'laws of the State of Nebraska in the <br />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 <br />Tax Lien' an extension of an effective lien, it serves to continue the priority of the state's interest in the affected properly of the taxpayer. <br /> <br />308 535-8294 <br /> <br /> <br />Revenue Agent <br />Title <br />Revenue Senior Agent <br />Title <br /> <br />IO-Id.-Ob <br />Dale <br /> <br />Telephone Number <br />If) '-/~ -OS <br /> <br />Date <br />4-494-1974 Rav_ 2-2002 Supersedes 4-494-1974 Rev, 10-1995 <br /> <br />sign ... <br />here ... <br /> <br />~[ <br />