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01/04/2005 16:27 FAX 14024714429 NEBRASKA UCC Q003/004 <br />Or <br />nebraska <br />department <br />of revenue <br />HE bet d $4649 UCC STL <br />2005OOt5l. <br />9905369930-0 Pas: I <br />JENSEN BRIAN IFF <br />Filed: e1ie4/2005 02:30 PM <br />Notice of State Tax Lien <br />PLEASE DO NOT WRITE IN THIS SPACE <br />1NDIVIDUAW'.. INCOME TAX <br />Saco SEC • wee, <br />514,396002,11 <br />ht=3.1* I;E*,qT MOO <br />16979 5' <br />S0C.!;SEE* me* <br />TAXABLE YEA,, <br />LIEN NO* <br />041700067 <br />COUNTY <br />HALL <br />RkIAN LEE JENSZEN <br />DATE Uf NOTICE <br />06f x/2004 <br />2064 W 12TO ST <br />SATE 3F AS-SZSSM NT <br />04/29/2604 <br />GaAvD ISLAND ME 6SBD1 <br />THIS NOTICE 0P STATE TAX LIEW IS ISSUED BY THE NEBRASKA DEPARTNEWIT OF <br />REVENUE FaP.j1-,%D1V1VJAL INVOME TAX PURWANT TO THE REVENUE LAWS Of THE <br />SiA—m OF BRAS :A• OTICS IS HEREBY SIVENJK-AIT INDIVIDUAL IMCDWE <br />TAXES FEUDING PENALTIES AND INTERESTv WNICH. ARE SHOWN BELOW ARE: DIE <br />I A <br />F,Zlom THE TA AYER SPECIFIED ASUSY-E ANO REMAIN UNPAID AFTER DEMANDa <br />THESE 1AXTT_ <br />i-ONSTITUrE A LIEN IN TFX COUNTY FOR PROPER MBELONSING '11"D <br />1 HE TAXPAYER 0"R HEREAFTER Ar,"'1R-C!-)* <br />AMOU4,110F TAX <br />?VNAL-Ty a a• <br />lifiREST (COMPUTED TO 06/18/2004) Z,6.60 <br />-foT. " AmuuAT DUE <br />HEREBY Ci.E�Tlfy THAT THE NEBRASKA DEPARYMEN1 OF REVENUE 14AS CUMPLIED <br />WITH THE -ftEVENUE LAWS OF THE STATE OF: AEBRASKA 111-41 THE DETERMINATION OF <br />THE AMUtNT §HOWN Ta BE DUEY AND THE TAXPAYER HAS FAILED TO PAY THE <br />I <br />AiOU-14T 3U=, AFTE-R DIEMANf- IF THIS NOTICE Of STAT E -AX J TER IS AN <br />EXTENSIG9 nF <br />I A -= - <br />�FfECT-VF, LI-;j IT S:,:?,VZS -0 --2--N`T-jWE THE PRIORITY OF <br />Z ST.AT-7$S!INTE7FEST'TN TH= AFFECT=D ?R0E-,-=FTy OF THE: TAXPAYER* <br />r7 <br />41 -(� <br />...... ...... <br />DATF/TELEPHONE <br />EPARERIS TURE TITLE <br />4? 0 . . . . . . . rl.f,,- <br />A1,11T AT RE TITLE SATE <br />NEBRASKA DEPARTMENT OF REVENUE - White and Canary Copies TAXPAYER - Pink Copy <br />Pfintcd with soy ink on recycled p.P. 7-145-1979 Rev- 2-20M Supersedes 7-145-1979 R�- 10-1996 <br />