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04/28/2010 FTED 14:36 FAX 402 471 4429 UCC SECRETARY OF STATE ~~~ Hall <br />~~ <br />201002841 <br />Please Return To: <br />Nebraska Department of Revenue <br />4500 Ave I PO Box 1500 <br />Scottsbluff, NE 69363-1500 <br />X002/002 <br />NE 5re a+' Skakn Jehn A G~lo - u[C 5TH <br />9910825829-9 pgs: 1 <br />pEPUE MIKE <br />Fllad: 0/28/2010 10:22 AM <br />•- N~ska Department of <br />REVENUE NOTICE OF STATE TAX LIEN <br />www.revcanuu.nka.gov <br /> PLEASE DO NOT WRITEIN THIS SPACE <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 kaxes 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 for real and personal property belonging to the taxpayer <br />or hereafter ac uired. <br />Nebraska Identi icatian Number Federal Identification Number <br />39747239 <br />Lien Serial umber Lean Filed With Soaa Security Number Spouse's Social Security Number <br />1103$827 ®Register of Deeds County Cleric XXX-XX-0938 XXX-XX-2491 <br />Date of Lien lien Type County <br />04/23/2010 ®Original Continuation Corrected Nq~L <br />BUSINE55 NAME AND LOCAT ION ADDRESS TAXPAYER NAMt: AND MAILING ADDRESS <br /> MIKE: ~ ROl3ERTA J pEPUE <br /> 117 E GOURT ST <br /> GRAND ISLAND NE 68801 <br />Tax <br />Category <br />Number lax Period Date of <br />Assessment Amount of Tax Penalty Interest Additions Balance of <br />Assessment Due <br /> <br />22 2007 05!20/2009 2,547.61 1,208.$0 459.37 4,215.48 <br />22 ZODB 05/06/2009 1,131.00 56.55 57.79 1,245.34 <br /> <br /> <br /> TOTAL ~ e,a6o.82 <br />I hereby certif y that the Nebras ka Department aF Revenue has complied w ith the revenue laws of the State of Nr+hracka in rho rra rorminarinn ,.r rho <br />amountshown to be due, and the taxpayer has failed to pay the amauni due after demand. If this Notice of Stale Tax Lien is an extension of an <br />eftegive lien, its es~ ca inue the riority of the slate's interest in the affected properly of the taxpayer. <br />~~_~ ~ er ~~- Taxpayer Services 5~ecialist II 04/23/2010 (30i)~32-12~~ <br />sign Preparers5ignature Trtle Date Telephone umber <br />here ~ Revenue ~,~~~~" ~,,~ 04/23/2010 <br />Aut prized Signature Title __.__~. Date <br />4484-1874 Rev. 2-Y00; Supersedes 4.494.1974 Rev. 1G-1985 <br /> <br />