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ADAMS COUNTY, NE
INST. N0. F..=O f ~ 10 2
Date - o-o Time -~15 ~
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REGISTER OF DEEDS
1tESERVED I+ OR REGISTER OF DEEDS RECORDING SPACE
ADAMS COUNTY NE
PAGE 1 OF ~ PAGES
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11/20/2007 TUE ]. 2:1i Fr`.k S02 47i 9429 UCC SECAETARZ OP STe1TE -~~- Aeiarna
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STATE UP NEBF.ASICA
DBPAI;<7'MEN'f OF REVENClE
ISI 1 WEST2H0 S'f STE 460 ,
GRAND ISLAND NC 68803
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200'75102
NOTICE OF STATE T~RX L9EN
7his.Notice of State Tax Lien is issued by tine Nebraska Department of
Revenue for unpaid taxes pursuant to the revenue laws of the state of
Nebraska. Notice is hereby given that taxes including penalties and
interest, which are shown below, are due from the taxpayer specified
below and remain unpaid after demand. These taxes constiEute a lien
in the county for real and personal property belonging to the taxpayer
or hereafter acquired. _
r---~ 10(25/2007 ~Criginal QContinuation ~COrreclzd Adams
t BUSINESS NAME AND LOCATION ADDRESS __ __ TAXPAYER NAME AMD MP.ILING ADDRESS ---~
Nebraska Idenl~catlon Number Federal Identification Number
9886683
Llan Serlal Nurnber ~ LieO Fifed VJlth Social Security Number Spouse's Sociai Securty Number
Register of Deeds ^ Couniy Clerl< 505-82-1189
Uale of Lien Lion Type County
business Name ~ Name
John Hagemann
Sheet Address ~~ Street or Other Mailing Address
315 N. Delaware
City. ~ State ~ Zip Code City 1 State Zip Code
4Jacfinne Ne. 68901
lax
Category
TaxPenod ~
Date of
i
Amount of Tax
Penalty
Interest
Additions
Balanceof
Assessment Due
Nurnber 1 Assessment
---- ~ ,
~, ---f --- ~ ,
21 a nu ueuu r 10l25l20U7 ~ 100.00 25AG 3.90 Izn.au
03(311200 % _,_ _
21 04/01/2007 10/25/2007 1tlG.0U 25.00 1.88 126.88,
06/30/2007 _.- --
TOTAL $ 255.78
I }lereby certify that the Nebraska Uepanment of ReYenue has curnptied xdih the revenue lawsof the Stale cf Nebraska in the
determination of the amount shown to be due, and the taxpayer has failed to nay the amountdue after demand. If this Notice of State
?ax Lian is ension of an effectyeiijr„ it serves to continue the priority of the state's interest in :he effected property of the taxpayer.
j 308 385-6075
~ c ,,_ _ Reve;fue.A~ent __ ~ Ua "
sign pre arer'sSignat re Titie Dale Telephone Number
here ~` o / _. Senior Reyenue'Agent // E
Authonzed S~`gnatuFe Tile Da e
4494-~79r4 Ra~.2.2002 9uprnedoa x.494-59i4 Ryr. 101/9j9S~``ya~
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