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05/28/2009 THU 13:40 FAX 4p2 471 4429 UCC SECRBTAIlY OF STATE yyy Hall <br />fl~ <br />Please forward ta: <br />Nebraska Department of Revenue <br />4500 Ave I PO Box 1500 <br />Scottsbluff, NE 69363-1500 <br />,..:, 200904.11 <br />~J003/003 <br />we s,^ ^r st^~^ John p G^~^ _ l1C[ rea <br />9909997966-1 Pac: 1 <br />()OMBROW$KI DFACRAH p <br />Filed: 05/28/2009 09;4]' AM <br />,~~ , ~ State Tax Lien Statement of Termination or <br />~E~1„ME Certificate of Partial Release or <br />wu.r,r.. ~,.~e e,... n.. a~.~r <br />Subordination <br />PLEASE DO NOT WRITE IN TMIS SPACE <br />Pursuant to the revenue laws of the State of Nebraska, notice is hereby <br />given that the State Tax l.len which has been duly filed by the Nebraska <br />Department of Revenue against the below-named taxpayer, is <br />terminated, partlalty released, or subordinated to the extent indicated <br />below. <br />Nebraska Identification Number Federal Identification Number Social Security Number Spouse's Social Security Number <br />16245261 XXX-XX-2254 XXX-XX-81$0 <br />Lien Serial Number Lien tiled with Date of Lien Tax Category County <br />32550515 ©Register of Dseds County Glerk 01/09/2008 22 Hall <br />BUSINESS NAME A ND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business-Name .. Name <br /> Robert L Decd 8 Deborah D Dombrowski <br />Street Address, Street or Mailing Address <br /> 422 N White <br />City State Zp Code Gity State Zip Code <br />. Grand Island NE 68803 <br /> Type of Action <br />TERMINATION QF TAX LIEN. The State Tax Lien is hereby fully terminated. UCC Instrument Number 99085427420 <br />County Instrument Number 200 1 <br />TAX YFJIRS (corporate, individual income, and withholding tax only) 2002, 2003, 2004 <br />PARTIAL RELEASE. The State Tax Lien is partially released as follows: UCC Instrument Number <br />County Instrument Number <br />TAX YEARS (corporate, tndlvfdual income, and withholding tax only) <br />SUBORDINATION. The State Tax Lien is suborciinated as follows. UCC Instrument Number <br />_. ~ County Instrument Number <br />I here Wily that the N asks Department o Revenue has camp ~s with the revenue laws of the State a Nebraska in <br />detenni on of the ermin Q, pa "al release, or subordination indicated above. <br />sign Revenue Agent 05/20/2009 308 632-1200 <br />herB Pre s i to Title Date Telephone Number <br />Revenue Su ervisor 05/20/2009 <br />Authorized Sig ure Titie Date <br />4.2828 Rev. 8~6 Supersedes 4-,'t3~~8 Rev. 10.85 <br />