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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 - 12/31/2015 <br />08/09/2016 <br />360_.00 <br />72.00 <br />7.72 <br />.00 <br />439.72 <br />Total <br />439.72 <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 />12135372 <br />Federal ID Number <br />474983449 <br />Lion Serial Number <br />11678730 <br />Lien riled With <br />Social Security Number <br />XXX -XX -0682 <br />Spouse's SoClal Seoarity Number <br />r1 Register of Deeds • County Clerk <br />Date of Lien <br />October 7, 2016 <br />Lien Type: <br />Qcorrected <br />County <br />HALL <br />Original D Continuation <br />Oct. 18. 2016 3:22FM NE Secretary of 'State — UCC No, 3417 F. 2'2 <br />Nebraska Department of <br />REVENUE <br />Business Name and Location Address <br />sign ,1 d ; <br />here 1�P repe <br />Authorized Signature <br />201606941 <br />Notice of State Tax Lien <br />y s s of li.te Jahn a Gel. - UCC srL <br />991B78141B -5 Figs, 1 <br />LA ROSA PEREZ RAIIIRO Y <br />Filed: 10/1812016 09:56 AM <br />Taxpayer Narita and Mailing Address <br />RAMIRO Y LA ROSA PEREZ <br />1021 WEST LOUISE ST <br />I certify that the Nebraska Department al Revenue has compiled wall the laws of the Slate of Nebraska in determining the amount shown to be due, <br />and that the taxpayer has felled to pay the amount due after demand. This Notice of State Tax Lien is an effective lien and serves in continue the priority of <br />the $Isle Interest In the affected pr of the taxpayer, <br />Revenue Senior Agent 10/07/2016 402 -471 -5727 <br />Title Date Phone Number <br />Revenue Senior Agent /0 1// , <br />Title Date <br />4454 -1974 Rao 5-2019 Supersedes 4440 -1574 Rev. 2.2002 <br />