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PtTaarxam TeX Period Assessment Tax Penalty Interest Costs Total Doe Individual 2014 05/1612016 1,114.00 55.30 50.64 1,219.94 Total $1,219.94 Oct.21. 2016 3:59FM NE Secretary of State — UCC Nebraska Oscartment of REVENUE This Notice of State Tax Lien 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 demand.These taxes are a Ilen for all property located in the county and rights to property owned by the taxpayer or acquired before the expiration of this lien. This lien will expire and become unenforceable 10 years after the date of recording it no continuation statement Is recorded on or prior to the expiration of the previous lien or continuation statement. Lied Filed Wtth: pig Register of Deeds ❑ County Clerk Sochi Security Number X X -XX -8878 Lien Type: ® an ❑ Conthuadon fl Corrected Business Name and Location Address Taxpayer Name and Mailing Address Nebraska ID Number 93887949 Uen Serial Number 11679161 Date of Lien 10/1912016 sig here flzed Signature Notice of State Tax Lien Title PLEASE DO NOT WRITE IN THIS SPACE Federal ID Number JOSE R GARCIA ANDRADE 618NELMST APT 3 GRAND ISLAND NE 68901 Tills Revenue Supervisor N... 3491 F. 3/5 201607037 NI Svc of 11.&. John A e.1n . uC STL gill 9916791550 -9 Pga: 1 GARCIR ANDRADE JOSE R Filed: 10/21/2016 02:29 PM Spouse's Social Security Number County HALL I certify That the Nebraska Department of Revenue has complied with the laws of the Slate of Nebraska In deterniining the amount shown to be due, that the lava as fall the am. due after demand-This Notice of State Tarr Lien Is an effective tan and series to continue the priority of ale's iota :: a'' r. I f Revenue Anent 10/19/2016 (402)471 -5731 Data Phone Number 10/1912016 Date 4-184.4871 Rev. 6.2013 Suparsadac 4949-1974 Row, 2.