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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 />01/01/2014 - 12/31/2014 <br />06/07/2015 <br />500.00 <br />100.00 <br />7.24 <br />,00 <br />607.24 <br />Sales <br />01/01/2013 - 12/31/2013 <br />06/07/2015 <br />500.00 <br />100.00 <br />22.24 <br />.00 <br />622.24 <br />Total <br />1,229.48 <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.Thls 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 I0 Number <br />9025235 <br />Federal 0 Number <br />412053034 <br />Lien Serial Number <br />11593506 <br />lien Filed With: <br />Q Register of Deeds 0 County Clerk <br />social Secunly Number <br />XXX-XX-0229 <br />Spouse's Social Security Number <br />Date of Lien <br />July 15, 2015 <br />Lien Type; <br />El Corrected <br />County <br />HALL <br />, <br />VII Original • Continuation <br />6- <br />Jul. 24. 2015 2:21FM NE Secretary of State — UCC <br />201505030 <br />nrpb.apcp 1cep pro <br />REVENUE <br />sign <br />here <br />Business Name and Location Address <br />Prepar a Signature <br />Autnerized Signature Title <br />ien <br />NE ec of S1a a John rl Gale - UCC STL <br />9915758387 -1 P9s <br />LAWHORNE JASON <br />Filed 07/24/2016 11:50 fin <br />No. 1940 F. 2 <br />Taxpayer Name and Mailing Address <br />JASON LAWHORNE <br />710 S KIMBALL <br />GRAND ISLAND NE 68801 <br />I certify that the 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 the -. payer has failed to pay the amount due after demand. This Notice of Slate Tax Lien. is an effective lien and nerves to continue the ono/ill( of <br />the SI: = a • -r in the affected rty of the taxpayer, <br />Revenue Agent 07/20/2015 402 -471 -6067 <br />Title Dale Phone Number <br />Revenue Senior Agent 7-2/-4-r <br />Date <br />4.494 -1974 Rev. 0 -2013 Supersedes 4- 909 -1974 Rev. 2.200 <br />