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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 />Withholding <br />10/01/2,013 - 12/3112013 <br />02/08/2015 <br />605.00 <br />211.75 <br />22.13 <br />.00 <br />838.88 <br />Total <br />838.88 <br />This Notice of State Tax Lien is Issued by the Nebraska <br />Department of Revenue for unpaid taxes administered by the Tax <br />Comrniseioner. Taxes, Including penalties, interest, and costs, <br />which are shown below, are due from the taxpayer and remain <br />unpaid after demand.These tuxes area Nen for all property located <br />In the country and rights to property owned by the taxpayer or <br />acquired before the expiration of this Iien.This 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 MUTE IN THIS SPACE <br />Nebraska ID Number <br />16669280 <br />Federal ?0 Nurhber <br />Lien Serial Number <br />11592382 <br />Lfr ft riled rwkc <br />E tiegtater of Deeds []Cony Civic <br />8oaal Security hit ,ntep <br />XXX-XX-3427 <br />Spouse's Social Security Number <br />Date of Lten <br />April 21, 2015 <br />Lien Type: <br />County <br />4LX. <br />i,.4 Original ❑ Conifnualfun <br />■ Crammed <br />Apr.28. 2015 2 :32PM NE Secretary of State — UCC <br />1t�IL -fir <br />Nebreeke Depellment ar <br />REVENUE <br />Business Name and Location Address <br />sign r . .. ' RevenueAeant <br />h ere rittsium ,tr rtue <br />Revenue Senior Agent <br />201502658 <br />Notice of State Tax Lien <br />Authorizer! Signature Title <br />TARA 1BLAKEtvfORE <br />2422 W 18T11 ST <br />GRAND ISLAND NE 68803 <br />No .0534 P. 2 <br />pa Sac or %tat• John A isle urC SR <br />111 111111111 <br />�II <br />V'l <br />saivsna B P96: 1 <br />E TARA <br />Feud: 0412R1281S 11;32 AM <br />Taxpayer Name and Mailing Address <br />I eereN L,w the Nebraska Department of Revenue has compaed with the laws dine We of Nebraska in determining the amount shown to be due, <br />and eel has tailed to a amount due after de mono les Notice of Sista Tax lien is an elledNe fen and Serves to centime the priority of <br />010 0021 In the aikct y of the taxpayer. <br />t 1 y!r /.feIs <br />Dale <br />402-471 -6061 <br />Phone Number <br />2/ - -2a1S <br />Dale <br />4-404-1274 n.k 04012 a,rtws.as 44ee2-t174 Rev. 24002 <br />