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Tax Program Tax Period Tax of Penalty Interest Costs Total Due Individual 2011 01/13/2014 221.00 11.05 29.10 261.15 Total $251.15 Mar. 16. 2016 3:04FM NE Secretary of State — UCC Nebraska Depaamem of REVENUE 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 aU property located in the county and rights to property owned by the taxpayer or acquired before the expiration of this Tien. This Pen Will expire and become unenforceable 10 years after the date of recording if no continuation statement Is recorded on or prior to the expiration of the previous lien or continuation statement. Nebraska ID Number 97574236 Lien Serial Number 11666979 Deta of Lien 03/14/2016 Sign here Ater .r/ sized Signature Notice of State Tax Lien Lien Fled With: ® Register of Deeds fl County Clark Lien Type: ® Origins ❑ conbnualion Business Name and Location Address 201601564 PLEASE D0 NOT WRITE IN THIS SPACE No. 5586 F. 2 HE Sae of 51ata Jelin R 6.1a - UCC STL t MN 9916770246 -1 Pus: HUSSE N MOHAMED I Fllod 03/16/2018 10:41 AM Federal b Number Social Security Number XXX -XX -6538 Spouse% Social Security Number count ❑ Corrected HALL Taxpayer Name and Mailing Address MOHAMED 1 HUSSEIN 1710 N BROADWELL APT 5 GRAND ISLAND NE 68803 I certify that the Nebraska Department of Revenue has complied with se laws of the Slate of Nebraska In deterniking the amount shown lo be due, and that the taxpayer has to pay the amount due alter demend. ills Notice of Stale Tax Lien Is an effective ten and serves to continue the priority of the St serest in the : :. cod properly of the taxpayer. - Revenue Agent 03/14/2016 Tale Date Revenue Supervisor Tile (402)471 -6043 Phone Number 03/14/2016 Dale 4041 ere Rev. 8-2013 300e01e0.w0- 9E9-1071 Rat 2 -2002 w