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Tax Program <br />Tax Period <br />Datc of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costs <br />Total Due <br />Sales <br />10/01/2014 - 12/31/2014 <br />02/02/2015 <br />.00 <br />- .00 <br />13.21 <br />20.00 <br />33.21 <br />Sales <br />04/01/2014 - 06/30/2014 <br />03/24/2015 <br />.00 <br />.00 <br />22.87 <br />.00 <br />22.87 <br />Saks <br />01/01/2015. 06/30/2015 <br />08/03/2015 <br />.00 <br />119.44 <br />16.91 <br />.00 <br />136.35 <br />Sales <br />07/01/2015 - 12/31/2015 <br />02/01/2016 <br />402.78 <br />96.09 <br />17,61 <br />.00 <br />516.48 <br />Sales <br />01/01/2016 - 06/30/2016 <br />11/01/2016 <br />.00 <br />25.00 <br />3.90 <br />.00 <br />28.90 <br />Total <br />737.81 <br />r--:Jan, 18. 2017 3:41FM ----NE Secretary c4 State — UCC <br />Nebraska Oaparment of <br />REVENUE <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 detnand.These taxes are a Tien 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 Ilen will expire and <br />become unenforceable 10 years atter 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 />Nebraska ID Number <br />11606606 <br />Lien Serial Number <br />11601172 <br />Date of Lien <br />December 28, 2016 <br />sign <br />here <br />Lien Filed With: <br />® Register 01 Deed$ ❑ County Clerk <br />Lien Type: <br />IN Original El Continuation <br />Business Name and Location Address <br />Prepay <br />prize . ignature Title <br />201700405 <br />Notice of State Tax Lien <br />PLEASE bO NOT WRITE IN THIS SPACE <br />Federal ID Number <br />463320311 <br />Social Security Number <br />XXX -XX -0469 <br />❑ Consoled <br />I certify that the Nebraska Department of Revenue has complied with the IaWa al the State of Nebraska In determining the amount shown to be due, <br />and that th = - xpayer has failed to pay t • unl due after demand. This Notice of State Tex Lien is an effective lien and serves to continue the priority of <br />the St:: -Q terest in the affected pr' Uie taxpayer- <br />Revenue Agent <br />Title <br />Revenue Senior Agent <br />1 I <br />County <br />HALL <br />CASS]E PRICE <br />4309 ASTER DRIVE <br />GRAND ISLAND NE 68803 <br />No. 9311- - - - - -F 2 - -- <br />NE See of Slake ighn a sot <br />9017785503 -8 <br />PRICE CRSSIE <br />Filed; 01/18/2017 11 :48 <br />Spouse's Social Security Number <br />Taxpayer Name and Mailing Address <br />AM <br />0/49•7 402 -471 -6067 <br />Date Phone Number <br />j• /I - - <br />Dale <br />4.494 -1974 Rev. 8 -2013 8uparcedec 49 lieu. 22002 <br />