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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 <br />01/01/2013 - 03/31/2013 <br />07/01/2013 <br />.00 <br />.00 <br />3.41 <br />.00 <br />3.41 <br />Sales <br />04/01/2013 - 06/30/2013 <br />01/04/2014 <br />1,155.00 <br />231.00 <br />37.02 <br />.00 <br />1,423.02 <br />Tire fee <br />01/01/2013 - 12/31/2013 <br />06/15/2014 <br />100.00 <br />35.00 <br />1.65 <br />.00 <br />136.65 <br />Withholding <br />04 /01/2013 - 06/30/2013 <br />01/04/2014 <br />100.00 <br />35.00 <br />3.11 <br />.00 <br />138.11 <br />'Withholding <br />01/01/2013 - 03/31/2013 <br />01/04/2014 <br />100.00 <br />35.00 <br />3.S7 <br />.00 <br />138.87 <br />Total <br />1,840.06 <br />This Notice of State Tax len Is issued by the Nebraska <br />Department of Revenue for unpaid takes administered by the Tax <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 hen for all property located <br />in the county and rights to property owned by the taxpayer or <br />acquired before the expiration of this Iierl.Thia lien will expire and <br />become unenforceable 10 years after the date of recording if no <br />continuation statement is recorded on or prior to the expiration of <br />the previous lien or continuation statement. <br />PLEASE DO NOT WARE INTHIS SPACE <br />NebeaSha Number <br />11491523 <br />Federal ID Number <br />4811480 <br />Lien seal Number <br />11488745 <br />Lien riled Watt: <br />Social Security Number <br />X.XX -jX -6377 <br />Spouse's Social Security Number <br />1 Register of Deeds 0 County Clear <br />Date of Lien <br />August 14, 2014 <br />Lien Type: <br />Courtly <br />BALL <br />A Original Q continuation <br />• Caarecled <br />Aug, 29. 2014 2:55PM NE Secretary of State — UCC No, 5441 P. 2 <br />Nebraska REV <br />sign <br />here <br />Business Nanma and Location Address <br />I certify plat the Nebraska Dopartmeft 01 Pleven,* has complied with the laws of the Stale of Nebraska in de ermuning the amount ehown 10 be due, <br />end None taxpayer has failed to pay the amou due all demand. TNa Notice of Stele Tax Lien is eh elective lien and serves b continue the priority of <br />the Siele'a interieet in Ow elected ydijei1y of the taxpayer. <br />here <br />/h <br />Aunroriaea Signature <br />201405396 <br />Notice of State Tax Lien <br />Revenue Agent <br />Title <br />CF4 L lteverme Senior Agent <br />'fide <br />ROY F. PALMER <br />147 E ROBERTS <br />GRAND ISLAND NE 68803 <br />NN 5.r: df Sian 4.h. A 4 . 1 . - W;c - u; ATl <br />Ih i' <br />9914741153 -O P ae: 1 <br />PRIMER ROY F. <br />Flied! 00128/2914 16.09 AM <br />Taxpayer Name and MaII ng Address <br />08/27/2014 402- 471 -6067 <br />Dale Phone Number <br />Date <br />4.404 -1974 fler.09013 eupersedae 4- 949-'874 ROW. 2-2CO2 <br />