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07/06/2010 TUE 15:1.7 FAX 402 471 4429 UCC SECRETARY OF STATE ~a~ Hd11 <br />o~ <br />Please return Copy to: <br />Nebraska Dept of Revenue <br />PO Sox 94$18 <br />Lincoln NE 48509 <br />Nebraska Department of <br />I~EE~~E <br />www.reavenue.ne.gpv <br />201004534 <br />id1002/006 <br />NE Ssc a1 S!r•tq John q O~lq -UCC STL <br />99A0631465_g Pgs: 1 <br />CHAGNON TIMOTHY R <br />Filed: 07/06/20!0 10;43 AM <br />NOTICE aF STATE TAX LIEN <br /> PLEASE DO NO I Ew fN 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 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 for real and personal property belonging to the taxpayer <br />ar hereafter ac uired. <br />Nebraska Idenli ication Number ederal Identification Number <br />34244824 <br />Lien Serial Number Lien Filed With Social Security Number Spouse's Social Security umber <br />11041380 ®Register of Deeds County Clerk XXX-XX-5314 <br />Date of Lien Lien Type County <br />07/01/2010 ®Qriginal Continuation ~Gorrected HALL <br />BUSINESS NAME AND LOCAT ION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br /> TIMOTHY R CHAGNON <br /> 202 1/2 N LOCUST ST APT B <br /> GRAND ISLAND NE 68801-5989 <br />Tax <br />Category <br />Number Tax Perfod Date of <br />Assessment Amount of lax Penalty Interest Additions Balance of <br />Assessment Due <br />22 2003 D3/10/20D9 7,198.65 1.799.66 2,864.28 11,$62,59 <br /> <br /> <br /> <br /> <br /> TOTAL $ 11,862.59 <br />I hereby certif y that the Nebras ka Department of Revenue has complied wi th the revenue laws of the s1a1e of Net,raaka .n lr,p ~1p ra~minarinn ~r rhp <br />amount shown to be due, and the taxpayer has failed to pay the amount due after demand. If this Notice of State lax Lien is an extension of an <br />effective lien, it serves to continue the priority of the state's interest in the affected property of the taxpayer, <br />`~~ r : ~. rl / ~ Revenue Agent 7~1 ~~~lo (402)471-6731 <br />Sl~fl Prep Sig lure Title Date ~ ~ ~~ Telephone Number <br />here - Revenue Su ervisor ! ~O <br />Authorized Sign Title Date <br />4-494-1974 Rev. 2.2a~2 SLpersedes 494-1974 Rev. 10.1995 <br /> <br />