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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 />Withholding <br />01/01/2015 - 09/30/2015 <br />06/17/2016 <br />490.00 <br />13176 <br />15.32 <br />.00 <br />639.08 <br />Withholding <br />04/01/2014 - 12/31/2014 <br />06/17/2016 <br />735.00 <br />257.25 <br />36.55 <br />.00 <br />1,028.80 <br />Total <br />1,667.88 <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 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 />PLEASE DO NOT WRITE IN THIS SPACE <br />Nebraska ID Number <br />8960216 <br />Federal ID Number <br />200787306 <br />Lien Serial Number <br />11698515 <br />Llen Filed With: <br />Social Security Number <br />X,XX_XX_1326 <br />Spouse's Social Security Number <br />pi Register of Deeds • County Clerk <br />Date al Llen <br />June 27, 2016 <br />Lien Type: <br />County <br />HALL <br />r <br />® Original ■ Continuation <br />■ Corrected <br />Jul. 15. 2016 3:42FM NE S ?cretary of State — UCC_. . -... <br />201604482 <br />Nebraska Departmentot <br />VENUE <br />sign <br />here <br />Business Name and Location Address <br />Notice of State Tax Lien <br />Revenue Agent <br />axpa <br />Time <br />Revenue Senior Agent <br />NE S.. aq E4. Jahn l <br />991E1776910 -B <br />8RRTLES RypN .3 <br />Filed: 07,19/2016 10:21 IN <br />er N ame an M ai li ng Ad <br />RYAN I BARTELS <br />2416 OVERLAND TRAIL, CIR <br />GRAND ISLAND NE 68803 <br />Vc.7346 F. 2;'2 <br />I certlly that 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 that the xpayer has failed to pay 1 cunt due after demand. This Notice al State Tax Lien is an eltecthe teen and serves to continue the priority of <br />the SI.. ereat in me affected pre Inc taxpayer. <br />7A�?�/lp 402 -471 -6067 <br />Date Phone Number <br />7— /7 ' 4 <br />Tine Dale <br />4494.1974 Hev. 9 -2013 Supersedes 4.49 -1974 Rev. 2.2002 <br />IA 4 L <br />