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Prog am Tax Period Assessment Tax Penalty Interest Costs Total Due Individual 2013 04111/2015 218.95 27.30 35.62 281.87 Total $281.87 Oct .20. 2016 3:45FM •NE Secretary of State — UCC Nebraska Department of REVENUE This Notice of State Tax Llen Is Issued by the Nebraska Department of Revenue for unpaid taxes administered by the Tax Commissioner. Taxes, Including penalties, interest, and costs, which are shown below, are due from the taxpayer and remain unpaid after dernand.These taxes are a lien for all property located in the county and rights to property owned by the taxpayer or acquired before the expiration of this Iien.This lien will expire and become unenforceable 10 years after the date of recording If no continuation statement is recorded on or prior to the expiration of the previous lien or continuation statement. Nebraska ID Number 43148670 Lien Serial Number 11679109 Date of Lien 10/18/2016 sign her Aulnotlzed Signature Notice of State Tax Lien Lien Filed With: ® Register of Deeds D County Clerk Federal ID Number Social Security Number XXX -XX -8281 Lien Type: © Original f Continuation JCorrected Business Warne and Location Address CLIFFORD H SHAFER 715 W 3RD ST GRAND ISLAND NE 68801 I certify that the Nebraska ' * : meant of Aavenue has complied with the laws of the Stale of Nebraska in determining the amount shown to be due. and that Cie IaXpaiyer has tal r f. pay the amount due after demand. This Notice of Stale Tax lien is an effective ken and serves to continue the priority of the S ; s- interest the d i property of the taxpayer. 1 4 AMMO Revenue Apent PLEASE DO NOT WRITE IN THIS SPACE . Title Revenue Supervisor Title NE See of at.+. Jahn A gale County HALL 241646%96 Taxpayer Name and Malling Address Spouse's Social Security Number - UCC ST nr r 9916761466 -0 Pas: SHAFER CLIFFORD H ,FiInd: 10/20/2016 10 :24 RIl (402)471 -5789 Phone Number 10118/2016 Dale `4 04-1074 Rev-8,2M Supersedes 6948 -1171 Het. 2-2002