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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 />Sales <br />01/01/2015 - 03/31/2015 <br />01/24/2016 <br />.00 <br />25.00 <br />.00 <br />_00 <br />25.00 <br />Sales <br />04/01/2015 - 06/30 /2015 <br />01/24/2016 <br />.00 <br />25.00 <br />.00 <br />,00 <br />25.00 <br />Sales <br />07/01/2015 - 09/30/2015 <br />01/24/2016 <br />.00 <br />25.00 <br />.00 <br />.00 <br />25.00 <br />Withholding <br />01/01/2014 - 03/31/2014 <br />08/08/2014 <br />.00 <br />4.59 <br />.21 <br />.00 <br />4.80 <br />Withholding <br />04/01/2014 - 12/31/2014 <br />08/11/2015 <br />300.00 <br />75.00 <br />13.01 <br />.00 <br />388.01 <br />Total <br />467.81 <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 />PL ASE DO NOT WRITE IN THIS SPACE <br />Nebraska ID Number <br />9381767 <br />Federal ID Number <br />Lien Serial Number <br />11698724 <br />Lien Flied With- <br />® Register of Deeds ❑ County Clerk <br />Social Security Number <br />?{20(_X}( -6453 <br />Spouse's Social Security Number <br />Date of Lien <br />July 12, 2016 <br />Lien Typo: <br />❑ Corrected <br />County • <br />HALL <br />[1�C Original II Continuation <br />• <br />Nebreeks Department of <br />Jul. 22. 2016 3:32FM. •NE Secretary of State — UCC <br />REVENUE <br />Business Name and Location Address <br />sign <br />h ere Prepar 's Si4aafur <br />uthorized Signature <br />Notice of State Tax Lien <br />Revenue Agent <br />Title <br />Revenue Senior Agent <br />Title <br />NE Sec of Si.i ohn R Ga e - U[[ ST <br />ADAM D. GRUPE <br />7500 SKY PARK ROAD <br />GRAND ISLAND NE 68801 <br />9916777330 -7 <br />GRUPE ADAM D. <br />Filed: 07/22/20% 11:08 AM <br />Taxpayer Name and Mailing Address <br />.1 <br />Pas: <br />I certlly that the Nebraska Department of fievenue has complied with the laws of the State of Nebraska In determining the amount shown to be due. <br />and that the taxpayer has tailed to pay punt due Oar. demand. This Notice of Slate Tax Lien Is an effective lien and Serves to continue the priority of <br />me S jlnierest In the affected p + 1 of the taxpayer. <br />07/18/2016 402 - 471 -6067 <br />Date Phone Number <br />2- /7 /A <br />Date <br />4-494 -1974 Rev. 5-2015 Supersedes 4-9494974 Rev. 2 -2002 <br />IA. r <br />