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Tax Pr gram Tax Period Ascs Tax Penalty Interest Costs Total Due Individual ,. 2011 04/14/2015 363.00 18.15 40.58 421.73 i Total $421.73 Jul, 20. 2015 3 :12PM NE So:r etary of State - UCC PLEASE RETURN TO: NEBRASKA DEPT OF REVENUE PO BOX 94609 LINCOLN NE 68509 -4609 Ne�aelde DeeaNneht or REVENUE I I f: • Nebraska ID Number 9756739 Lien se ial Number 11554792 Dale of lien 07/16/2015 Business Name and Location Address 201500:04 Notice of State Tax Lien This Notice of State Tax Lien is issued by the Nebraska Department of Revenue for unpaid taxes administered by the Tax Commissioner. Taxes, including penalties, Interest, and costs, which are shown below, are due from the taxpayer and remain unpaid after demand.These taxes are a lien for all property located In the county and rights to properly owned by the taxpayer or acquired before the expiration of this Iien.This Ilan will expire and become unenforceable 10 years after the date of recording If no forkrthe the previous lien or continuation statement. Lien Had Wilk ® Register of Geed D County Clerk PLEASE DO NOT WRITE IN THIS SPACE Federal It) Number Social Security Number XXX -XX -0338 Lien Type: Noon' DContiruw4on ❑ Corrected SAVANNAH A [DAL 1407 SOUTH NEW CASTLE APT 108 GRAND ISLAND NE 68801 N, 1863 F'. 4- 4.c of S4.fo John A bat - IJCC STL I 9915758069-7 Gas: t3AL SAVANNAH A Filed: 07/20/2015 01:53 P11 Spouse's Social Security Number County HALL Taxpayer Name and Mailing Address l of Revenue has complied with the laws of the State of Nebraska in determining the amount shown to be due, the amount due after demand. This Nolice of State Tax lien Is an effective lien and serves to contimre the priority of perry otlhe taxpayer, Revenue Agent 07/16/2015 (308)632 -1210 Title Date Phone Number Revenue Supervisor 07/16/2015 Title Date A-464-1974 Rev 6-2013 Supersedes 4949 -1914 Bev. 2-2002