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Tax Program <br />Tax Period <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costa <br />Total Due <br />Individual <br />2012 <br />07/21/2016 <br />1,109.00 <br />277.25 <br />112.48 <br />1,498.73 <br />Individual <br />2013 <br />07/21/2015 <br />405.00 <br />101.25 <br />28.93 <br />635.18 <br />Total <br />$2,033.91 <br />Sep. 7. 2016 3:04PM NE ._:rotary .:f .tats — UCC <br />Nebreeka Department of <br />REVENUE <br />Nehreeke ID Number <br />47803177 <br />Lien Serial Number <br />11676730 <br />Date of Lien <br />08/3112016 <br />sig <br />here) <br />®originel <br />Business Name and Location Address <br />201605852 <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 IIen.Thls 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 />Lien Fried With <br />® Hester of Deeds 0 County Clerk <br />Lien Type: <br />Federal ID Number <br />Social Security Number <br />XXX- XX-3729 <br />❑ Continuation []Corrected <br />JOSE LOZANO <br />818 W 14TH ST <br />GRAND ISLAND NE 68801 <br />I certify that i he ebraska Department . ' e hee complied with the laws of the Stale of Nebraska In determining the amours shown to be due, <br />0 Ural the lax . has ^ to pay tie unt due after demand. This Notice of Slate Tax Ilan Is an effective lied and serves to oontnue the priority at <br />ate 's irte - tis properly a : 1 :. 4.. <br />ly .. A._. / Number 08/31/2018 (402)471 -5731 <br />Signature / Title Dale Phone Number <br />i / Revenue Supervisor 08131/2016 <br />The <br />Authorized Signature <br />Revenue Agent <br />PLEASE DO NOT WHITE IN THIS SPACE <br />N3. 792E F. <br />NE S..o of 51ato John A Gala . liGE STL <br />County <br />HALL <br />Spouse's Social Security Number <br />Taxpayer Name and Mailing Address <br />Date <br />9918779532 Pao: 1 <br />LoZANO JOSE <br />Filed: 09!0712016 10:31 AM <br />4484 -1974 Rev. a-2013 Supersedes 4948 -1974 Rev, 2-2002 <br />