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Tax Program <br />Tax Period <br />Datc of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costs <br />Total Due <br />Sales <br />04/01/2015 - 10/31/2015 <br />05/28/2016 <br />7,965.90 <br />1,618.16 <br />318.00 <br />.00 <br />.9,902.06 <br />Total <br />9,902.06 <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 lien.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 />6684696 <br />Federal 0 Number <br />470766690 <br />Lien Serial Number <br />11698751 <br />Lien Filed With: <br />Social Security Number <br />Mr.X_gX_08I8 <br />Spouse's Social Security Number <br />f Register of Deeds • County Clerk <br />Date of Lien <br />May 28, 2016 <br />Llen Type: <br />County <br />HALL <br />E Original • Continuation <br />El Corrected <br />J ul , 21. 2016 3:45EM NE Secretary c,f State — UCC <br />Nebraska Department of <br />. REVENUE <br />sign <br />here <br />Business Name and Location Address <br />Prepares Signal , e <br />Authorized Signature <br />'2016046:1 <br />Notice of State Tax Lien <br />NE S.. of <br />7400 H 2 <br />5tats on It Cal - uCC CT <br />9918777276 -1 Pgs: <br />STAROSTKR GARY L. <br />Mad: 07/21/2016 10:37 AN <br />Taxpayer Name and Mailing Address <br />GARY L. STAROSTKA <br />663 FAIDLEY CT APT. #1 <br />GRAND ISLAND NE 68 803 <br />I certify that the Nebraska Department of Revenue has complied with the laws of the State of Nebraska In determining the amount shown to be due, <br />and that the taxpayer has failed to pay th - aunt due after demand. This Notice of State Tax Lien is art affective Getz and Serves to Continue the priority of <br />the SIs+ Merest to the affected pr r of the taxpayer. <br />Revenue Agent 7 /,cr/ G . 402- 471 -6067 <br />Title Date Phone Number <br />Revenue Senior Agent • <br />Title Dale <br />44e4.1974 Rev. 92013 Gupersedee 4.949.1574 ReV, 2.2002 <br />