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04/15/2009 WED 12:24 PAX 402 471 4429 UCC SECRE~ARY OP STATE ~~~ Hall lilI002/009 tJJ 200902822, Please forward to: Nebraska Department of Revenue 4500 Ave I PO Box 1500 Scottsbluff, NE 69363-1500 ,~ IN...bo.....k. D_~"l of' REVENUE www.I..\I.I!.t.....n..G..... NOTICE OF STATE TAX LIEN PLEASE WRITE IN THIS SPACE This Notice of State Tax Lle,n Is Issued by the Nebraska Department of Revenue fotunpald taxes pursuant to the revenue laws of the state of Nebraska. NoUce.l,he~by' given th,at taxes,lnchlding penalties and interest, which are shown below, are due from the taxpayer specified below and remain unpaid after demand. These taxes constitute a lien in the county for real and personal property belonging to the taxpayer or hereafter acaulred. Nebrasklfldentifk:ation Number Federal Identification Number 11757817 Lien Serlal Number Lien Filed With Social Security Number Spouse's Social Security Number 90370066 I!JRegister of Deeds DCounty Clerk XXX-XX-7091 XXX-XX-1356 Date of Lien Lien Type County 04/0812009 I!JOrlglnal Dcontlnuation o Corrected Hall I BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS I Business Name Name George W & Donna R Peterson Street Address Street or other Mailing Address 1918 Grand Island Avenue City ~ra[e Zip Code City State Zip Code Grand Island NE 68803 Tax Category Tax Period Date of Amount of Tax Penalty Interest Additions Balance of Number Assessment Assessment Due 22 2005 10/18/2006 1,538.00 104.05 332.80 1,974.85 22 2007 10/21/2008 432.00 21.60 30.42 484.02 , TOTAL $ 2,458.87 .. hereby certi that the Nebraska Department of Revenue has com lied with the revenue laws of the State of Nebraska in the detenmnation of the Revenue Agent Title Revenue Supervisor Title 308632-1200 Telephone Number 04/08/2009 Date 4...94.1974 R.v. 2-2002 SUpersedes 4-"94-1974 Rev. 10.1995 cjJ sign here 04/0812009 Date