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<br />01/07/2009 WED 15:20 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br /> <br />1dI002/002 <br /> <br />o'il <br /> <br />200900109 <br /> <br />1111111," <br /> <br /> <br /> <br />F~ORES JESUS J Pgs: 1 <br />FIled: 01/07/2009 10:23 AM <br /> <br /> <br />~ <br />N.,b.......k... o..."..,.....,..nt al: <br /> <br />REVENUE <br /> <br />w.w'W _~'G''''''vr."lllljl.c..''li._iil.::..:u\ <br /> <br />NOTICE OF STATE TAX LIEN <br /> <br /> PLEASE 00 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 /> 40750434 <br />Lien Serial Number lien Filed With Social Security Number Spouse's Social Security Number <br /> 72080164 00 Register of Deeds DCounty Clerk XXXwXXw6881 <br />Date of Lien Lien Type County <br />01/06/2009 [2g Original 0 Continuation o Corrected HALL <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name Name <br /> JESUS J FLORES <br />Street Address Street or Other Mailing Address <br /> 10036 HOLLAND CT <br />City ::itate Zip Code City State Zip Code <br /> BROOMFIELD CO 80021 <br />Tax <br />Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of <br />Number Assessment Assessment Due <br />22 2004 05/10/2007 712.00 35.60 187.81 935.41 <br /> TOTAL $ 935.41 <br /> <br />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 <br />amount shown to be due, and the taxpayer has failed to pay the amount due after demand. If this Notice of Stale Tax Lien is an extension of an <br />effective lien, it serves t continue e priority of the state's interest in the affected property of the taxpayer. <br /> <br />sign <br />here <br /> <br /> <br />01/06/2009 <br />Date <br /> <br />402471-5928 <br />Telephone Number <br /> <br />REVENUE AGENT SUPERVISOR <br />TiUe <br /> <br />01/06/2009 <br /> <br />Date <br />4-494-1974 Rev. 2.2002 Supersedes 4494-1974 Rev. 10.1995 <br /> <br />'V <br />