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O1/18/2011 TU8 14:23 FAx 402 471 4429 UCC SECRSTARY OF STAT� ��� Ha11 <br />i� <br />74rrbrqsk+t CY�Prkr'IY�+���R oM <br />I�ODS/OQS <br />N� ;�c o� S\�1s John A 6ela - yGC STL <br />99116485.5' 1-9 Pas: 1 <br />CLUB fi9, INC. <br />Filed: 01l16/2011 10:32 RM <br />2oiiao4�� <br />I FiE'1�E�'1M�E NOTICE OF STATE TAX LIEN <br />vrww,.� wrrn.�..�. r4r. Cl�r v <br />PLEASE Dp NOT WRITE IN THIS SPACE <br />This Notice af State Tax Lien is issua�i by the Nehraska Department of <br />Revenue for unpaid taxes pursuant tQ the revenue laws of the state of <br />Nebraska. Notice is hereby given tha taxes including penalties and <br />interest, which are shvwn below, are ue from the taxpayer specified <br />below and remain unpaid after dema d. These taxes constitute a Ilen <br />in the county for real and personal p perty belonging to the taxpayer <br />or herea�ter acauired. <br />9677Dp3 <br />Q�G <br />�X F�egister af Deeds �County <br />12/03/2010 I �c <br />BUSINESS NAM� ANp l.qCATIQN <br />Category Tax Period Date of <br />Num6er Assessment <br />01 �1/01/2b1� 12 <br />01/31/2Q10 <br />�� 02/01/201D �2�03/2p10 <br />02 /2812q 1 D <br />01 Q��a1/2Q10 12/R3/2010 <br />03/31 /201 p <br />20-3858058 <br />vw� n� <br />�Continuatipn �Corrected HqLL <br />SS TAXPAYER NAME AND MAILING ADDRESS <br />Amount oF Tax <br />785.00 <br />930.D0 <br />785.00 <br />CLUB 69, INC. <br />:t or Other Mai ing Address <br />��9 w. �R� sr. <br />GRAND ISLAND <br />Penalry Interest <br />157.00 30.22 <br />1$6.00 32.23 <br />157.00 23.$7 <br />N � 68801 <br />Additions Balance of <br />Assessmant �us <br />972.22 <br />1,148.23 <br />965.87 <br />T�TAI. I $ 3,086.32 <br />�������r ������r ���a< <��� ��cv�aona unpp��n�Crn o� vernue nas campnea wim [ne revenue laws ot the 5tate of Nebraska in the determination oi the <br />amount shown to 6e due, and the taxpayer has fa d to pay the amaunt due after demand. If this Notice nf State Tax Lien is an extension of an <br />effective lien, it serv • continue the pri of t state's interest in the affected property af the taxp�yer. <br />B• r7� �' Revenue A ent c� � i.z � o� 402 471-6067 <br />sign Preparers ignature Tide Date Telephone Numbar <br />here 8 Senior Revenue A ent ./"../ <br />horized Signature Titls Date � <br />4-A9�-797412ev. 2-2002 Suparsedas 4-494-7874 Rev. 10.1985 <br />