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03/04/2010 THU 15:10 FAX 402 471 4429 UCC $SCRETARX OF STATE ~yy Hdll <br />o~ <br />201001447 <br />Please forward ta: <br />Nebraska Department of Revenue <br />4500 Ave Y PQ Box 1500 <br />Scottsbluff, NE 69363-1500 <br />~002/D02 <br />NH See .f Sl~4~ John A eelr + uCC iTL <br />FORSYTME RUSSELL 0 JR <br />Filed: 03/04/2010 08:26 AM <br />• <br />Nebraska Department of <br />~'~IEN~~ NOTICE OF STATE TAX LIEN <br />www: (avenue. r1.e.g ov <br />• PLEASE DO NO~ITETN'rAfS BPAC <br />This Notice of State Tax lien is issued by the Nebraska Department of <br />Revenue for unpaid-taxes pursttant to the ni:venue laws •of the state of <br />~Ielpreska. Notice is heeby#y given•that,taxes i,ncluding ~per~alties,and _ - <br />interest, which are shown below,. are°due from the tairpaye~ 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 ac uired. <br />Nebraska (dent flcation Number Federal Identi capon um r <br />201294$3 <br />Lien 5 al Num r en it With Socal 5ecunry m r Spouse's Social Security Number <br />11036629 ®Register of Deeds ~Counry Clerk XXX-XX.•5413 XXX-XX-3074 <br />Date of Lien ten ype County <br />03/01/2010 ~ ®CriginalContinuation Corrected HALL . <br />BUSINESS NAME AND. LOCA TIDN.ADDRES5 TAXPAYER NAME AND MAILING ADDRESS <br /> RUSSELL O & LORI FORSYTHE JR <br /> 4014 BUCKINGHAM DRIVE <br /> GRAND ISLAND NE 6$803 <br />ax <br />Category <br />Number Tax Period Date of <br />Assessment Amount of Tax Penalty Interest Additions Balance of <br />Assessment Due <br />2Z 2007 10/24/2008 11,255.00 993.75 1,286,64 13,545.39 <br />22 2008 10/24/2009 9,826.00 876.30 430.73 11,135.03 <br /> <br /> <br /> <br /> TOTAL. $ 2assa.42 <br />hereby verb tat e~as <br />amount shoHm to be due, d t ka Departm~t Ot <br />he taXt'1a~1e7 has f avenue as complied Huth a revenue laws o State of Nebras a in the determination of the <br />ailed to nav the ameuinf d~~ affwr dpmanri Ir rh~4 N~x~,. „t c~sre rs„ i ~a., :. a„ a„~a..a:.... ,.r -.. <br />1/2010 (30832-1206 <br />Telep one um r <br />03/01/2010 <br />Date <br />4.484.1 W4 Rav. 2.2002 Supuseda 4494.1971 Rav.10.1895 <br />effective lien, it serves dconBn a the: wiry f the state's interest in the affected property of the taxpayer <br />Revenue Agent 03/0 <br />SIg11 c ature i afe <br />here ^ Revenue Su ervisor <br />Authorized 5i re Title <br /> <br />