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Program rn <br />9 <br />Tax Period <br />Assessment <br />Penalty <br />Interest <br />Costs <br />Total Due <br />individual <br />2011 <br />07124/2015 <br />887.00 <br />221.75 <br />121.12 <br />1,229.87 <br />individual <br />2012 <br />07/24/2015 <br />. 2,070 -00 <br />614.02 <br />191.07 <br />2,875.09 <br />Individual <br />2013 <br />07/2412015 <br />204.00 <br />51.00 <br />12.71 <br />267.71 <br />r <br />Total <br />$4,372.67 <br />May. 17. 2016 3:27FM NE Secretary of State — UCC <br />Nebraska Department or <br />REVENUE <br />Notice of State Tax Lien <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 llen.This lien will expire and <br />become unenforceable 10 years after the date of recording it no <br />continuation statement is recorded on or prior to the expiration of <br />the previous nen or continuation statement. <br />Nebraska ID Number <br />46536175 <br />Lien Serial Number <br />11670721 <br />Sign <br />her <br />Lien Filed Wilk: <br />IN Register of Deeds 0 County Clark <br />Dale of Lien Lien Type: <br />05112/2016 IN origins ❑ Cortlti ualio h <br />Business Name and Location Address <br />Federal ID Number <br />Social Security Number <br />XXX -XX -0297 <br />D <br />natant t of Revenue has complied with the laws of the Stare of Nebraska In determining the amount shown in be due, <br />pay the amount due alter demand. This Notice of State Tax Lien Is an effective lien and serves to oon tnue tie priodly or <br />ad property or tb <br />prized Signature <br />Title <br />PLEASE DO NOT WRITE IN THIS SPACE <br />N- 6558 P. 2/2 <br />201603077 <br />I C S.e•f tc..ba d.nn 0 bale <br />{ <br />9916774058 -6 <br />FALLDORF JASON B <br />Filed: 05/17/2016 11:27 AM <br />Spouse'e Social Security Number <br />County <br />Corrected HALL <br />Taxpayer Name and 'lolling Address i <br />JASON B FALLDORF <br />3754 NORSEMAN AVE <br />GRAND ISLAND NE 68803 <br />Revenue A ! - nt 06/12/2016 (402471 -6043 <br />Title Dale Prone Number <br />Revenue Supervisor 05/12/2016 <br />Date <br />4 - 404 Her. 8-2013 Supersedes 4-949-1074 Ray. 2.2002 <br />- UCC CTL <br />Pea 1 <br />