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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 />12/01/2012 -_ 12/31/2012 <br />04/28/2013 <br />.00 <br />42.97 <br />24.67 <br />.00 <br />67.64 <br />Sales <br />01/01/2013 - 01/31/2013 <br />04/28/2013 <br />.00 <br />37.50 <br />23.99 <br />.00 <br />61.49 <br />Sales <br />08/01/2012 - 08/31/2012 <br />04/28/2013 <br />.00 <br />35.11 <br />18.02 <br />.00 <br />53.13 <br />Sales <br />06/01/2012 - 06/30/2012 <br />04/28/2013 <br />.00 <br />38.90 <br />19.59 <br />.00 <br />58.49 <br />Sales <br />02/01/2013 - 02/28/2013 <br />06/03/2013 <br />250.00 <br />40.50 <br />28.68 <br />.00 <br />319.18 <br />Withholding <br />07/01/2012 - 09/30/2012 <br />04/28/2013 <br />181.10 <br />45.28 <br />15.84 <br />.00 <br />242.22 <br />Withholding <br />10/01/2012 - 12/31/2012 <br />05/02/2013 <br />219.52 <br />43.90 <br />16.77 <br />.00 <br />280.19 <br />Withholding <br />01/01/2013 - 03/31/2013 <br />05/10/2013 <br />104.09 <br />5.20 <br />7.20 <br />.00 <br />116.49 <br />Total <br />1,198.83 <br />This Notice of State Tare 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 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 II 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 />10290958 <br />Federal ID Number <br />. <br />Lien Serial Number <br />11593966 <br />Lien Filed With: <br />Social Security Number <br />XXX-XX-9614 <br />Spouse's Social Security Number <br />XXX -XX -0022 <br />pi Register of Feeds II County Clerk <br />Date of Lien <br />August 18, 2015 <br />Lien Type: <br />© Original 0Conbnuation <br />County <br />HALL <br />■ Corrected <br />_p. 17. 201 2 28EM NE Secretary of State - UCC No.2696 F. 2 <br />Nebraska Department Of <br />REVENUE <br />sign <br />here <br />Business Name and Location Address <br />Prepa prs Signature <br />Authorized Signature <br />201506362 <br />Notice of State Tax Lien <br />Revenue Agent <br />Title <br />Revenue Senior Agent <br />Title <br />DONN & VICTORIA HICKOK <br />PO BOX 133 <br />CAIRO NE 68824 <br />NE 3..c of St..* John n ea e - rice STl <br />9915760882 -5 PER 1 <br />HICKOK DONN <br />Filed! 09/17/2016 01:26 PM <br />Taxpayer Name and Mailing Address <br />I certify thal 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 ihal the Taxpayer hes failed to pay th - - nt due atter d8rnand.This Notice of Stale Tax Lien s an effective hen and serves to continue the priority of <br />the Si te'y ih tarsal in the affected prop •i a taxpayer. <br />Dale <br />402 -471 -6067 <br />Phone Number <br />Date <br />4.454.1974 Rev. 8 -2013 Supersedes 4.949 -1974 Rev. 2.20(12 <br />