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02/16/2010 TUE 15:13 FAR 402 471 4429 UCC SECRETARY OF STATE y-~y Hall <br />o~ <br />Please forward to; <br />Nebraska Department of Revenue <br />4500 Ave I PO Box 1500 <br />Scottsbluff, NE 69343-1500 <br />~oiooioss <br />Nebraska Department of <br />REVENUE <br />www.revenuo.n.e.gov <br />~004/OD4 <br />N[ f~c ei f!~!^ Jehn A pel^ -UCC 5TL <br />9910$1996$-5 pgf: 1 <br />BEFIR@NS LARRY <br />Filed: 02!16!2010 11:0fi RM <br />NOTICE OF STATE TAX LIEN <br /> PLEASE DO NDT WRITE IN TWIS SPACE <br />This Notice of State Tax Lien is issued by the Nebraska Department of <br />Revenue for unpald 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 tastes constitute a lien <br />in the county for real and personal property belonging to the taxpayer <br />or hereafter ac uired. <br />Nebraska ldenti lion Number Federal Idenh cation Number <br />40998905 <br />Llen Serial Number Lien File ith Social Security Number Spouse's Social Security umber <br />11036147 ®Regisier of feeds County Glerk XKX-XX-1483 <br />fate of Lien Lien ype County <br />02/11/2010 ®Driginal Continuation ~Carrected HALL <br />BUSINESS NAME AND LOCA TIQN ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br /> LARRY 13~HR~NB <br /> 2323 B~LLWOOD DR 95 <br /> GRAND ISLAND NE 68801 <br />Tax <br />Category <br />Number Tax Period Date of <br />Assessment Amount of Tax Penalty Interest AddlNons Balance or <br />Assessment Dua <br />22 2004 12!30!2008 458.00 114.50 145.97 718.47 <br />22 2005 12/30/2008 835.00 208.75 216.03 1,259.78 <br />22 2006 10/18/2008 329.00 82.25 63.48 474.73 <br /> <br /> TOTAL $ 2,452.98 <br />I hereby certif y that the Nebras a Department of Revenue has compli w ith the revenue aws of the State of Nebraska in rhP dp tniminalinn nr n,o <br />amount shown to be a and the taxpa <br />effective lien, it serv continue the ri <br />51911 ign <br />here - <br />Authorized Sig <br />{has failed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of an <br />pity of a slate's interest in the affected property of the taxpayer. <br />Revenue Agent 02!11/2010 (308)632-1208 <br />it ate elephone Number <br />Revenue Su ervisar 02!1112010 <br />Title Date <br />4494-1974 Rav. 2.2pD2 supersedes 4.494.1874 Rev.1o-1995 <br /> <br />