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02/08/2010 MDN 15:06 FAX 402 471 4429 UCC SECRETARY qF STAT); ~~~ Hall <br />o~ <br />Please forwazd to: ~ ~ i ~ ,~ ~ ±~ +~ <br />Nebraska Department of Revenue <br />4soo Aver Po sox 1 soa <br />Scottsbluff, NE b93b3-1500 <br />0~,. ~AfA Jahn A n-~. <br />~oo~/oo~ <br />Nebraska Department of <br />RE'V'ENGE NOTICE OF STATE TAX LIEN <br />www.revenue.ne.gov <br /> PLEASE DO N WRIT N 15 PAC <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 shown below, are due from the taxpayer specified <br />below and remain unpaid after demand. These taxes constitute a lien <br />in the county far real and personal property belonging to the taxpayer <br />or hereafter ac aired. <br />ebra den Pion umber Federal Identi cation Number <br />44603029 <br />Lisn um er Lien Filed With Soda) Secaxiry Number pouses od eaariry Num r <br />11035864 ®Regist~ of Deeds ~Caunry Clerk XXX-XX-0029 <br />Data of Lien en ype County <br />02!0.4/2010 ®Arigirfal Continuation Corrected HALL <br />BUSINESS NAME AND LOCA TION ADDRESS TAXPAYt:R NAME AND MAILING ADDRESS <br /> MIGUEL JORGE POL <br /> 1316E 5TH ST APT A <br /> GR4ND ISLAND NE 68801 <br />Tax <br />Category Tax PvMod Data of Amount of 1'ax Penalty Interest Additions Balance of <br />Number Assessment Assessment Due <br />22 2005 01/23/2009 718.00 35,90 185.07 938.97 <br /> <br /> <br /> <br /> <br /> TOTAL ~ $ 938.97 <br />I hereby at a Nebras <br />anlDUnt St10NR1 t0 tie du~nd t ka Departrnent of <br />he tax4avechas f Revenue has oompl' wi the revenue laws of a tale of raslta in the eferminatian the <br />ailed to Oav the amount due offer drYnarxl If fhic Nntira of Sfafra Tav I ian Ic an arFancinn of an <br />4/2010 (308)632-1208 <br />T ephone um <br />02/OM2D10 <br />Dale <br />4-494197 Rev. 2-2002 Supersadii ~•~6FtY74 Rav.1o•tO95 <br />effective lien, it dwntinue the p~ firy aF the state's interest in the affected property of the ta~ayer. <br />` Revenue Agent 0210 <br />S1~11 e ~ i to I e Date <br />here - Revenue S~rvisor <br />Autho ' S1 are Title <br /> <br />PUL MI6UEl<'~~6 --•. •• '..roll <br />Filed: 02/0620,0 Pfrs: i <br />11:08 RM <br />