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Tait <br />Category <br />Number <br />Tax Period <br />nern■/nn4n <br />Date of <br />Assessment <br />Amount of Tax <br />Penalty <br />Interest <br />— <br />Additions <br />Balance of <br />Assessment Due <br />6 +3 <br />Sep. 18. 2013 2:56PM NE Secretary of State - UCC <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 clue 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 acquired. <br />Nebraska Identification Number <br />Lien Serial Number <br />/ /30 /fc. / <br />Date of Lien <br />Business Name <br />Street Address <br />City <br />01 <br />01 <br />01 <br />01 <br />01 <br />sign <br />here <br />11240393 <br />09/13/2013 <br />BUSINESS NAME AND LOCATION ADDRESS <br />02/29/2012 05/01/2012 <br />Preparer's Signature <br />Ize• Signature <br />Lien Filed With <br />Q <br />• %.rb.4 ■ke aarel.rnrr brl WI <br />Lien Type <br />201307663 <br />REVENUE NOTICE OF STATE TAX LIEN <br />Register of Deeds []County Clerk <br />Federal Identification Number <br />Original ['Continuation 0Corrected <br />Stale zip code <br />0.00 <br />Name <br />• Revenue Agent <br />Title <br />CHRIS GREEN <br />Street or Other Mailing Address <br />10437 CR 270 <br />C ity <br />f`API Il lkl!`TV1kl <br />10.32 <br />26- 3482260 <br />Social Security Number <br />XXX -XX -2922 <br />County <br />HALL <br />Ds <br />1.79 <br />No. 0960 P. 2 <br />as Si e of Sliete John 9 Selo - UCC r<TL <br />1 I <br />II � I <br />Il II ! i! II I II I I f <br />9913722936—g F9s: 1 <br />FFiled 09/10/2018 02:10 PR <br />PLEASE DO NOT WRI`FE IN THIS SPACE <br />Spouse's Social Security Number <br />TAXPAYER NAME AND MAILING ADDRESS <br />State <br />Revenue Senior Agent <br />Title Date <br />4404 - 1974 Rev. 2 - 2002 Supersedes 4 - 494 - 1974 Rev. 10 - 1995 <br />zip Code <br />03/01/2012 <br />03/31 /2012 <br />04/01/2012 <br />04/30/2012 <br />05/01 /2012 <br />05/31/2012 <br />08/01/2012 <br />06/30/2012 <br />06/01 /2012 <br />07/28/2013 <br />07128/2013 <br />75.20 <br />07/26/2013 <br />0.00 <br />565.00 <br />565.00 <br />376.00 <br />56.92 <br />113.00 <br />113.00 <br />0.94 <br />29,30 <br />26.90 <br />16.37 <br />TOTAL <br />12.11 <br />57.86 <br />707.30 <br />704.90 <br />467.57 <br />$ 1,949.74 <br />I hereby cell that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in the determination of the <br />amount shown to be due, and the taxpayer has failed lo pay the amount due after demand. If this Notice of Stale Tax Lien is an extension of an <br />effective lien, It se to continue the priori the state's interest in the affected property of the taxpayer. <br />402 471 -6067 <br />Telephone Number <br />N ra� l� <br />