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5. 2016. 3:30FM; NE Secretary of State — ucc dl6UUU5 � <br />Nebraska Department <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 ere shown below, are due from the taxpayer and remain <br />unpaid after dBmand.These taxes are a lien for all property er or <br />In the county and rights to property bY <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 tP Number <br />94851050 <br />bell Serial Number uef Filed With: <br />11562985 ® peglater 01 Deeds ❑ County Clerk <br />Dale of Lien Lien Type <br />12/29/2015 IN Original ❑ Continuation <br />Business Name and Location Address <br />Tax <br />Program <br />Individual <br />Individual <br />sign <br />here <br />Tax Period <br />Notice of State Tax Lien <br />hate of <br />Assessment <br />Tax <br />2011 12/11/2013 301.38 <br />2012 1012912013 822.00 <br />Federal ID Number <br />Social Security Number <br />XXX XX -6520 <br />I realty that the NebrasWa De Amen' of Revenue has complied with the taws of the Stale of Nebraska in determining the amount shown to be due, <br />and that me taxpayer nes fat .1i . the amount due atler demand. This Notice of State Tax Lien is an effective lien and selves to continue the priority of <br />the State's interest in <br />Revenue Agent <br />Title <br />Revenue Supervisor <br />Title <br />PLEASE DO NOT WRITE INTHIS SPACE _ _ . . . <br />Penalty <br />PLEASE RETURN TO: <br />NEBRASKA DEPT OF REVENUE <br />PO BOX 94609 <br />LINCOLN NE 68509 -4609 <br />CHAD CLEMENS <br />423 W 5TH <br />GRAND ISLAND NE 68801 <br />Nil sec of 5le4+ John a Gale - UtC STL <br />9916706e46 -1 Pes: 1 <br />CLEMENS CHAD <br />Flied: e1/06/2016 10:07 AM <br />Spouses Social Security Number <br />County <br />corrected HALL <br />Taxpayer Name and Mailing Address <br />Interest Costs TotalOue <br />128.50 42.30 472.18 <br />41.10 66.75 929.85 <br />Total <br />12/29/2015 <br />Dale <br />3. 4390 F. <br />$1,402.03 <br />(308)632 -1206 <br />Phone Number <br />12/29/2015 <br />Dale <br />4494404 43 4 Rev. 6-2013 Superee0ea 4.9ae -1974 Nev. 2.2002 <br />