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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 />01/01/2012 - 12/31/2012 <br />05/01/2013 <br />.00 <br />36.89 <br />.65 <br />.00 <br />37 -54 <br />Sales <br />01/01/2013 - 12/31/2013 <br />08/12/2014 <br />470.00 <br />94.00 <br />20.02 <br />.00 <br />584.02 <br />Total <br />621.56 <br />This Notice of State Tax Lien is issued by the Nebraska <br />Department of Revenue for unpaid taxes 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 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 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 WRITE IN THIS SPACE <br />Nebraska ID Number <br />11491094 <br />Federal ID Number <br />Lien Serial Number <br />11593233 <br />Lien Flied With: <br />Social Security Number <br />)JCR - ) - 2249 <br />Spouse's Social Security Number <br />, <br />ri Register of Deeds • County Clerk <br />ogre of Lien <br />June 23, 2015 <br />Lien Type: <br />❑ Corrected <br />County <br />HALL <br />U Original II Continuation <br />Jul. 2. 2015 2:30FM NE Secretary of State. — UCC <br />Nsonexe Department of <br />REVENUE <br />201504454 <br />Notice of State Tax Lien <br />No.1586 F. <br />E se. of 5 +.4r John A <br />9915756980 -7 <br />CRRRILLO JOHN <br />Filed: 07/02/2015 01:52 PM <br />sign <br />here <br />ss Name and Location Address <br />uthorized Signature <br />Taxpayer Name and Mailing Address <br />301 CARRILLO <br />712 ORLEANS DR APT 6 <br />GRAND ISLAND NE 68801 <br />I certify That Inc Nebraska Department of Revenue has complied with the laws of the Stale of Nebraska In determining the amount shoWn to be due. <br />and that Inc taxpayer has tailed to pay tr • mount due alter demand. This Notice of Stale Tax Lien Is an effective lien and serves to continue the priority of <br />the SI .. . rest in the affected p • . ert 1 the taxpayer. <br />��. l! <br />2 <br />.1. - ucc STL <br />Pe a: 1 <br />Revenue Agent 06/29/2015 402 -471 -6067 <br />Prepare Signature Title Dale Phone Number <br />i/14 )ii Revenue Senior Agent <br />Title Date <br />4-494-1974 Rev. 9 -2013 Superoedes 4-949-1974 Rev. 2 -2002 <br />