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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 lien_This lien will expire and <br />become unenforceable 10 years alter 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 />PLEASE DO NOT WRITE INTHIS SPACE <br />Nebraska 1D Number <br />95628487 <br />Federal ID Number <br />Lien Serial Number <br />11673792 <br />Lien Filed With: <br />© Register of Deeds ❑ County Clark <br />Social Security Number <br />XXX -XX -5122 <br />Spouse's Social Security Number <br />Date of Lien <br />0612912016 <br />lien Type: <br />EA Original ■ Conunualton ■ Corrected <br />County <br />HALL <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address 1 <br />. <br />SHELLY A GREGG <br />4140 ELMWOOD DRIVE <br />GRAND ISLAND NE 68803 <br />Tax <br />Program <br />Tax Period <br />Date of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costs <br />Total Due <br />Individual <br />2013 <br />12117/2015 <br />.00 <br />290.92 <br />45.08 <br />336.00 <br />Individual <br />2014 <br />12/17/2015 <br />1,119.00 <br />299.84 <br />40.56 <br />1,459.40 <br />-- • <br />Total <br />$1,795.40 <br />Jul. 6. 2016 4:05PM NE Secretary of State — UCC No. 7268 P. 3.4 <br />Nebr,tke Deperrrnem e1 <br />sign <br />here <br />�J:✓� <br />P:f r.,� <br />Authori2011 Sig 711 "" <br />201604227 <br />Notice of State Tax Lien <br />9916776493 - 0 <br />GREGG 6HELLY R <br />Filed; 07/06l201a 12:01 PM <br />PLEASE RETURN TO: <br />NEBRASKA DEPT OF REVENUE <br />PO BOX 94609 <br />LINCOLN NE 68509 -4609 <br />ST <br />I certify that the Nebraska Department of Revenue has complied win the laws of the Stale of Nebraska in determining the amount shown to be due. <br />and that the taxpayer has fated to pay the amount due after demand. This Notice of Slate Tax Lien Is an effective lien and serves IO continue the priority of <br />the State's interest in the ailed ' properly or the taxpayer. <br />06/29/2016 (308)632 -1203 <br />Revenue Agent <br />Title Date Phone Number <br />Revenue Supervisor 06/29/2016 <br />TiSe Date <br />4-494-1974 Rev. B-2013 Superseder) 4 Rev. 2 -2002 <br />