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<br />10/06/2008 MON 15:57 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />1210031004 <br /> <br />ofJ <br /> <br />Please forward to: <br />Nebraska Dept of Revenue <br />4500 Ave I PO Box 1500 <br />Scottsbluff, NE 69363-1500 <br /> <br />200808544 <br /> <br />11111111111(1\ <br /> <br />9908572665-2 Pas. 1 <br />GR RNSELMA ARRIRZA <br />~~I~d: 10/06/200801:55 PM <br /> <br /> <br />~ <br />N',",~,....k., O....<aft......riI: eII'- <br /> <br />;REVENUE <br /> <br />"WwW.iI..v.............I.L.....II.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 ~enalties 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 Federalldentilication Number <br /> 98904000 <br />Lien Serial Number Lien Flied With <Isocial Security Number ISPouse's Social Security Number <br /> 80810089 [!I Register of Deeds Dcounty Clerk XXX-XX-9523 <br />Date of Lien Lien Type County <br /> 1 0102/2008 [!I Original DContinuatlon o Corrected Hall <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />BusIness Name_ Name <br /> Anselma Arriaza Ortega <br />Street Address Street or Other Mailing Address <br /> 615 N Eddy Street <br />City ::ilate 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 2005 11/01/2007 182.00 12.85 42.25 237.10 <br /> TOTAL $ 237.10 <br />I hereb certl that the Nebraska De artment of R v n com lied with the revenu I f .nat' <br /> <br />y fy <br />amount shown to be <br />effective lien, it seN <br /> <br />sign <br />here <br /> <br /> <br />e e ue has p e aws of the State 0 Nebraska In the determr Ion of the <br />as failed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of an <br />JY of the state's Interest in the affected property of the taxpayer. <br /> <br />Revenue Agent 10/02/2008 <br />Title Date <br /> <br />308 632-1200 <br /> <br />Telephone Number <br /> <br />Revenue Senior Agent <br />TiUe <br /> <br />10/0212008 <br />Date <br />4-494-197" Rev. 2-2002 Supersedes 4-494-1974 Rev. 10-1995 <br /> <br />& <br />