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06/17/2009 WSD 14:45 FAX 402 471 4429 UCC SECRETARY pF STATE ~yy Hall <br />X003/007 <br />D NR Sae vP St~tr Jahn A ONe - uCC STL <br />9909589783-5 Pgg: 1 <br />2 U U 9 U 4 ~i 7'7 FQ~ed':'~'0~%,7;a0~9 ~~;34 AM <br />.Please forwazd to: <br />Nebraska Department of Revenue <br />4500 Ave I PQ Box 1 S00 <br />Scottsbluff, NE 6g3b3-1500 <br />N. Ykr..Qlpurtm4p~R! <br />..; . <br />.,..- . <br />~'~ •~1'iVll~~~~' 10:. <br />..- : - - ,F!1,fc .. ~ '~FJI~ SPACE <br />.~ ._ <br />ADC . 'SAC., NQ~-..' - .. :~X~%'?~.~; ...,. , ~. - _' <br />- ,: .- - <br />~F~$R., ~.DFI~T ~p -... <br />~~r'.. <br />TAKE ~E - ~::.:' <br />LIUN lu1d: ~~q:~: ~ ~. <br />I?ATE OE` NOTZGF `Q~~~~~~~1~. d+'8::~3';.DP. .. .: <br />DATE ~F A55ESS.~IE~1~ ~:Q`;~~~~~d~:- [~~1:`...~'tAI~II~ :. ~E'. '.~~80.3 <br />,.. <br />,. <br />HIS <br />T N I . <br />„~ A~~:. <br />R'EVENTJ~ F@~: ~~~I~~k1 ~~C ~ ~~ <br />TPx~iES I~'~i,~H,~:~',{~. ~'~~I~-y~~I: I~:~yr' .~~~:':~•~ ::;~?~1'= ~ ~`~T <br />` :. ~ T~Q~ <br />FROM T ,~~~- ~ ...... ~E',~A•..,:: ~ ;~,~,:.. ..:. _ ~.... ~ ~. <br />.. <br />THE T~1~C'PAY.ER' 'O~ IEAF~ ~U'~:~'~.;,. <br />FENAL~r .... ~,9.. ~r0. <br />,. ~ ~ :~ <br />INTE1tEwT` {~~2D+1P~~~J~ .: b ~~ 5 I?.OOg Y r ... ., . .. .. ~. 1 ~3. <br />UNDERPAY~E.~1T '~ E,~~;IM~~'$D T~ PEI~LT.~ ::... ., . 0.OD <br />TQTAI, A~10U;~T -~uE .. .~. ~ - r~S,Z1 <br />I HEREBY !CER~''YF'Y .T~ :~'~~. ~1.~.~RASK~A .I~P,'~; ~ Q~' `I'~E~}UE HAS G171bP:~,~:kp <br />W T TH THE RE~VE~f1JE La~~S ,~E x~ STATE Q~` ~~~ _ .x:Tsi ~'H~ i~~`~~R14! I-~1iA~ Ik~1 Q~' <br />THE AMOUNT SITQFI~i TO `~E. i~U~:,; ~~~~ ~ TA3~F;A'~E~`~.~i~S, FAII,F~~ fi~ .SAY ~I~E <br />AMOUNT DUB P;F'~~R .~EMFiNI9 ti .. ~~ ~~ :.~iG~~~~CE C~'' ,~~~~. TAB. 'T,I'~1~ rS~ 'A'N . <br />EXTENSION aF AN .E~'.~F'ECTI #+'~:'V ~~ `~~E~VE~a ~~ .~:Q;~"~';X'1~i~E TAE. ~~~QRTfi'Y QF <br />THE TA~TE'a T£.RE~~T IN TH~.:~,4~~'~~ .F1~AP~"~',~~~':'E ~~X~'~'~ER. <br />E' AR, • ' S ,GN . . ' E TITLE ... .... . • - • DATA/~.!ET,EPHt7NE <br />..~~al~P.~ . ~~u~:c ,.~:. . , ... ~.lrs 1 ~aa~ .. . <br />A ITORIZEp 5~I'i~NA.TLIE T~I'~'I,E ~.~E <br />II~T7b f170B <br />