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Tax <br />Program <br />Tax Period <br />Dale of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Coats <br />Total Due <br />Individual. <br />2011 <br />04/1412015 <br />250.00 <br />12.50 <br />28.84 <br />291.34 <br />Total <br />$291.34 <br />yep, 1. 201) 3 00PM NE Secretary of :tat. — UCC <br />PLEASE RETURN TO: <br />NEBRASKA DEPT OF REVENUE <br />PO BOX 94609 <br />LINCOLN NE 68509 -4609 <br />Nebr:t D parmiant of <br />REVENUE <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 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 />Nebraska ID Number <br />• <br />96577835 <br />den Serial Number <br />11556993 <br />Date of Lien <br />08/28/2015 <br />Notice of State Tax Lien <br />Uen Filed With: <br />© Register or Deeds ❑ County Clerk <br />UenType'. <br />® Original <br />Business Name and Location Address <br />Title <br />PLEASE DO NOT WHITE IN THIS SPACE <br />Federal ID Number <br />Social Security Number <br />XXX -XX -5730 <br />❑ Continuation ❑corrected <br />MIGUEL DOMENECH <br />1520 WEST ANA ST <br />GRAND ISLAND NE 68801 <br />Spouse's soda, Security Number <br />courty <br />HALL <br />to 4-c ei $4.ic Jahn A Attie U <br />�_.._ 1111. <br />N. -, 2455 F. 2 <br />Taxpayer Name and Meiling Address <br />99 1 576021 1 -4 <br />DOMENECH MIGUEL <br />Filed: 09101!2016 10:07 PM <br />I certify that are Nebraska Department of Revenue has complied wIthlhe laws of the Stale of Nebraska kr determining the amount shown to be due, <br />and that the taxpayer has tailed to pay the amount due after demand, This Notice of Slate Tax Lien Is an effective len'ard servos to continua the priority of <br />the Stales rest In the affected property of the taxpayer. <br />Revenue Senior Agent <br />TAia <br />Revenue Supervisor <br />08128/2015 (304)632 -1205 <br />Dale Phone Number <br />08/28/2015 <br />Date <br />4- 494-1974 Rex 42013 atlyer➢eaes 4940 -1071 Rev. 2 <br />Pas- 1 <br />