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06/07/2010 MON 14:24 FAX 402 471 4429 qCC SECRETARY OF STATE -~yy Hall <br /> <br />Please Return To: <br />Nebraska Department of Revenue <br />~F500 Ave I PO Box 1500 <br />Scottsbluff, NE 69363-1500 <br />2oioc~3so7 <br />Nebraska pepartment of <br />REVENUE <br />wwvy:ravenue.ne.gav <br />f~oo2/ooz <br />N6 5qc oP 5!a!v Jahn A 6aly - UCC STL <br />99106Z936Z-3 Pgs: 1 <br />RQ14ER0 RNGE,L R <br />Filed: 06!07/2010 12:85 PPt <br />NOTICE OF STATE TAX LIEN <br /> PLEABE DO NOT WRITE IN THIS 5 AC <br />This Notice of State lax Lien is issued by the Nebraska Department of <br />Revenue for unpa(d 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 unpa(d after demand. These taxes constitute a lien <br />in the county for real and personal property belonging to the taxpayer <br />ar hereafter ac wired. <br />N ska Idenu cation Number Federal IdentiFcation Number <br />88392484 <br />Lien Serial Number Lien File With Social Secunty umber Spouse's Sadal Security Number <br />11040258 ®Register of Deeds County Cleric XXX-XX-7210 <br />Date of lien Lien Type County <br />06/02/2010 ®Originai ~Continuatinn Corrected HALL <br />BUSINESS NAME AND LOCAT ION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br /> ANGEL A ROMERO <br /> 308 W HEDDE APT 16 <br /> GRAND ISLAND NE 68803 <br />Tax <br />Category Tax Period Date of Amount of Tax Penalty Interest Additlans Balance of <br />Number Assessment Assessment Due <br />22 2006 05/17!2009 286.00 14.30 59.54 359.84 <br /> <br /> <br /> <br /> <br /> TOTAL $ 359.84 <br />I hereby certif y that the Nebras ka Department of Revenue has complied w ith the revenue laws of the fate o Nebraska in the rlP farminatinn 1 a <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 serves continue the priority of the slate's interest in the affected property of the taxpayer. <br />(• ~ Revenue Senior Agent 06/02/2010 (30832-1205 <br />sign r r s ' atur_e _ Title Oate Telephone Num r <br />here ^ Revenue Su ervisor 06!02/2010 <br />arized Signature Title pate <br />4.184-187< Rev. 2.2D02 Supuaedea A~B4-1 W4 Rev. ta1995 <br /> <br />