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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 />05/01/2015 - 05/31/2015 <br />08/03/2015 <br />132.36 <br />25.00 <br />6.91 <br />.00 <br />164.27 <br />Sales <br />06/01 /2015 - 06/30/2015 <br />11/02/2015 <br />_116.44 <br />25.00 <br />4.29 <br />.00 <br />145.73 <br />Sales <br />11/01/2015 - 11/30/2015 <br />02/01/2016 <br />112.76 <br />25.00 <br />2.72 <br />.00 <br />140.48 <br />Sales <br />12/01/2015 - 12/3I/2015 <br />04/01/2016 <br />151.83 <br />25.00 <br />3.26 <br />.00 <br />180.09 <br />Sales _ <br />07/01/2015 - 10/31/2015 <br />04/01/2016 <br />66.50 <br />100.00 <br />8.16 <br />.00 <br />174.66 <br />Sales <br />01/01/2016 - 03/31/2016 <br />06/01/2016 <br />370.15 <br />50.00 <br />6.22 <br />.00 <br />426.37 <br />Sales <br />04/01/2016 - 07/31/2016 <br />09/01/2016 <br />_ 483.53 <br />100.00 <br />3.82 <br />.00 <br />587.35 <br />Withholding <br />01/01/2015 - 03/31/2015 <br />08/10/2015 <br />.00 <br />2.07 <br />.27 <br />.00 <br />2.34 <br />Total <br />1,821.29 <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.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 INTHIS SPACE <br />. <br />Nebraska ID Number <br />11801654 <br />Federal ID Number <br />464209680 <br />Lien Serial Number <br />11600026 <br />t,ien Filed with; <br />Social Security Number <br />XXX -XX -3837 <br />Spouse's Social Security Number <br />1 Register ol Deeds 0CountyClerk <br />Date of Lien <br />October 7, 2016 <br />Lien Type: <br />County <br />HALL <br />® Original Ili Continuation <br />• Corrected <br />Oct. 20. 2016 3:45PM NE Se.retary of State - UCC <br />Nebraska Department of <br />REVENUE <br />sign <br />here <br />Business Name and Location Address <br />Notice of State Tax Lien <br />APRIL HARDY <br />380 N BROADWELL AVE <br />GRAND ISLAND NE 68803 <br />Revenue Agent lr/f�ce0 /(v <br />Tide Dale <br />Revenue Senior Agent <br />'title <br />E Se.. of S {a {a John q G.le IICC i <br />TL <br />991e781457 - 2 Pgs; 1 <br />HARDY APRIL <br />• Filed: 15/20/2015 10:29 API <br />Taxpayer Name and Mailing Address <br />I certify that the Nebraska Deparimenl of Revenue has complied with the laws of the State of Nebraska in determining the amount shown to be Clue, <br />and lnal the taxpayer has failed to pay the • + t duo after demand. This Notice 01 State Tax Lien is an effective lien and serves to continue the priority of <br />the Slate' �� sl in the affected pros taxpayer. <br />402 -471 -6067 <br />Phone Number <br />Dale <br />4 .4 94.1974 Rev, 8-2013 Supereedee 4949 -1974 Rev. 2-2002 <br />