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06/24/2D09 tQED 13:25 FAX 402 47]. 4429 L1CC SECRETARY pF STATB y-~y Hall <br /> <br />Please rctum to: <br />STATE OF NEERASKA <br />DEPARTMENT OF REVENUE <br />1811 WEST 2"'" ST STE 460 <br />GRAND IST,AND NE 68803 <br />~ooa/ooz <br />NE Sar ai S{s!e John A Gala - UC[ ST4 <br />8908800559-0 P85= 1 <br />CLUB 69, YNC. <br />Filed: 06/24/2069 09:18 RM <br />2ooso5os7 <br />IFifar~~kie iGlrprre w~ <br />'w~` +s ~~ <br />NOTICE OF STATE TAX LIEN <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 Shawn 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 acauired. <br />9677003 <br />203658058 <br />ORegister of Deeds County <br />06/22/2009 QOriginal Continuation <br />BUSINESS NAME AND LOCATIpN ADDRESS <br />Category Tax Period <br />Number <br />01 06/01 /2006• <br />04/30/2009 <br />Date of Amount of Tax <br />Assessment <br />06/04/2009 ~ 5,034.17 <br />Corrected ~ Hall <br />TAXPAYER NAME AND MAILING ADDRESS <br />Club 69, Inc. <br />t or ether Mai ing Address <br />106 E Third St <br />State <br />Grand Island NE <br />Penalty ,Interest Additions <br />1,843.80 I 470.10 <br />68801 <br />Balance of <br />Assessment Due <br />7,348.07 <br />TOTAL ~$ 7,348.07 <br />~ ne~auy ~nuy u;a~ me iveprasKa uepar[mem or Kevenue nos wmplied 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 State Tax Lien is an extension of an <br />effective lien, it serve a con inue prio ity of the state's int t in the affect pro rty of the taxpayer. <br />g 308 385-6073 <br />Slgfl reparer's Signatu ite Date ~ e phone Number °" <br />here ~ ~ ~ <br />utho ' S' toe die ~ <br />4.494-197A Rev. 2,2002 Supersedes 4~f94-1874 Rav.10-1995 <br />Y <br />