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Tax Program <br />Tax Period <br />Date of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costs <br />Total Due <br />Sales/Use <br />08/0112011 - 08/31/2011 <br />10/04/2011 <br />228.72 <br />25.00 <br />_ 24.64 <br />.00 <br />278.36 <br />SaleslUse <br />09 /01/2011 - 09/30/2011 <br />10/1912011 <br />218.20 <br />.00 <br />22.61 <br />.00 <br />240.81 <br />Sales/Lise <br />11/01/2011 - 11/30/2011 <br />01/03/2012 <br />244.69 <br />25.00 <br />23.48 <br />.00 <br />293.17 <br />Sales/Use <br />12/01/2011 - 12/31/2011 <br />02/0212012 <br />255.94 <br />25.59 <br />23.47 <br />.00 <br />305.00 <br />Sa1es/1Jse <br />01/01/2012 - 01/31/2012 <br />03/01/2012 <br />222.22 <br />25.00 <br />19.43 <br />.00 <br />266.65 <br />Sales/Use <br />02 /01/2012 - 02/29/2012 <br />03/14/2012 <br />222.09 <br />.00 <br />18.54 <br />.00 <br />240.63 <br />Sales/Use <br />03/01/2012 - 03/31/2012 <br />05/0112012 <br />.00 <br />27.34 <br />1.95 <br />.00 <br />29.29 <br />Sales/Use <br />04 /01/2012 - 04/30/2012 <br />06/01/2012 <br />.00 <br />25.00 <br />.55 <br />.00 <br />25.55 <br />Sales(Use <br />05/01 /2012.05/31/2012 <br />06/08/2012 <br />229.81 <br />.00 <br />16.29 <br />.00 <br />246.1D <br />Sales/Use <br />06/01/2012 - 06/30/2012 <br />08/01/2012 <br />202.70 <br />25.00 <br />13,53 <br />.00 <br />241.23 <br />Sales/Use <br />07 /01/2012 - 07/31/2012 <br />03/01/2013 <br />_ .00 <br />25 <br />.00 <br />Total <br />.25 <br />2,167.04 <br />This Notice of State Tax Lien is issued by the Nebraska <br />• Department 01 Revenue for unpaid taxes administered by the Tex <br />Commissioner. Taxes, including penalties, interest, and costs, <br />which are shown below, are due from the taxpayer and remain <br />unpaid after demand.These taxes are a lien for all property located <br />In the county and rights to property owned by the taxpayer or <br />acquired before the expiration of this lien.This lien will expire and <br />become unenforceable 10 years after the Mate of recording if no <br />continuation statement is recorded on or prior to the expiration of <br />the previous Ilen or continuation statement. <br />PLEASE D0 NOTWRITE IN THIS SPACE <br />Nebraska 10 Number <br />7009674 <br />federal 0 Number <br />470776255 <br />Lien Serial Number <br />11487780 <br />Lien Filed With <br />(J ROW** of oeeae D County Clerk <br />Social Securry Number <br />XXCX --XX -9068 <br />Spouse's Social Security Number <br />Dale of Lien <br />,tune 23, 2014 <br />l-ien Type: <br />® angina 0 Conlnuelwn 0 corrected <br />Gounly <br />TALL, <br />Aug, 4. 2014 3:01PM NE Secretary of State - UCC No, 6022 P. 3 <br />Na mere Pepertment or <br />REVENUE <br />Business Name and Location Address <br />sign <br />here P <br />rere SI. azure <br />razed Signs <br />Notice of State Tax Lien <br />Tate <br />DENNIS NELSON <br />501 N PINE ST <br />GRAND ISLAND NE 68801 <br />NE S. d ROO. Bonn n sale - UCC STL <br />99147381!39 -.5 Ppa <br />NELSON DEMIS <br />Fi1�d: aale4f2e14 00:42 LTM <br />201404821 <br />Taxpayer Name and Mailing Address <br />I certify that the Nebraska Department of I evenue nes compeers wain tee laws of the State of Nebraska in delermining the amount sham to be due. <br />end that the taxpayer has failed 19 pay the amount due alter demand, Thia Nonce at stale tax lien is an eeeetive lien and sarves to continue the priority of <br />the S Interest in the affected ly of the taxpayer. <br />Revenue Agent <br />Tine <br />Revenue Senior Agent <br />07/28/2014 402- 471 -6067 <br />Dale Phone Num <br />Dale <br />4494.1974 flea. 0-20 Supersedes 4- e40-19)4 Poi. 24002 <br />