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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 />01/01/2010 - 12/31/2013 <br />06/24/2014 <br />1,279.45 <br />1,200.00 <br />990.19 <br />60.00 <br />3,529.64 <br />Sales <br />01/01 /2014 - 11/30/2014 <br />03/01/2015 <br />142.61 <br />500.50 <br />20.77 <br />.00 <br />663.88 <br />Sales <br />12/01/2014 - 12/31/2014 <br />08/03/2015 <br />53.23 <br />25.00 <br />3.14 <br />.00 <br />81.37 <br />Sales <br />01/01/2015 - 08/31/2015 <br />10/01/2015 <br />559.28 <br />150.00 <br />30.55 <br />.00 <br />739.83 <br />Sales <br />09/01/2015 - 09/30/2015 <br />12/01/2015 <br />.00 <br />25.00 <br />.55 <br />.00 <br />25.55 <br />Sales <br />10/01 /2015 - 10/31/2015 <br />03/01/2016 <br />.00 <br />25.00 <br />.29 <br />.00 <br />25.29 <br />Sales <br />12/01/2015 - 12/31/2015 <br />03/01/2016 <br />.00 <br />25.00 <br />.36 <br />.00 <br />25.36 <br />Sales <br />01/01/2016 - 04/30/2016 <br />07/01/2016 <br />.00 <br />75.00 <br />.95 <br />.00 <br />• 75.95 <br />Sales <br />05/01/2016 - 05/31/2016 <br />08/01/2016 <br />.00 <br />25.00 <br />.33 <br />.00 <br />25.33 <br />Sales <br />06/01/2016 - 06/30/2016 <br />08/05/2016 <br />.00 <br />25.00 <br />_00 <br />.00 <br />25.00 <br />Total <br />5,217.20 <br />This Notice of Slate Tax Lien is issued by the Nebraska <br />Department of Revenue for unpaid taxes administered by the Mx <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 IN THIS SPACE <br />Nebraska 1D Number <br />11820845 <br />Federal ID Number <br />Lien serial Number <br />11601173 <br />Lien Filed With: <br />N Register of Deeds fl Count Clerk <br />Social Security Number <br />XXX -XX -3834 <br />Spousea Social Security Number <br />Date of Lien <br />December 28, 2016 <br />Lien Type: <br />County <br />HALL <br />EN Origins! II continuation <br />• Corrected <br />Jan, 26. 2017 3:35FM NE Secretary cf State - UCC No. 9427 P. 2 <br />Nebraska Department of <br />REVENUE <br />20170058g <br />Notice of State Tax Lien <br />NE Roe of 34a4. John N Bela - UCC STL <br />9917785010 -2 Pas: 1 <br />- maw 11d; St/ 12:45 PM <br />sign <br />here Pre¢ <br />Bus(ness Name and Location Address <br />Au orized Signature <br />Tine <br />Tax <br />a er Name and Maitin <br />.IEREM'Y T ITMAN <br />2615 COCI-IIN <br />GRAND ISLAND NE 68801 <br />Address <br />1 certify that the Nebraska Department of Revenue has complied with the laws of the State of Nebraska In delermining the amount shown to be due, <br />and that the taxpayer has failed to • . e amount due after demand. This Notice of stale Tax Lien is an effective lien and serves 10 continue the prtorlty of <br />tweet in the a = pro • =rry oI the taxpayer. <br />Revenue Agent 6/ //7�u7ai 402 - 471 -6067 <br />Title Data Phone Number <br />Revenue Senior Agent <br />/ -/9/7 <br />Dale <br />4.494 -1974 Rev, 5-2010 Superse0as 4949.1974 fiee.2.2002 <br />