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May. 2. 2017 3:54FM NE __.r tary of 'State — UCC <br />Nebraska Department 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 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 lien. 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 />Nebraska ID Number <br />1198289 <br />Lien Serial Number lien Filed With: <br />11786588 ® Register 01 Deeds <br />Date of Lien Lien type: <br />April 18, 2017 ® original <br />Business Name and Location Address <br />sign <br />here <br />0 Continuation <br />the Ste = es1 in the affected Pr • • = r[y a e taxpayer. <br />thonzed Signature <br />2017028 <br />Notice of State Tax Lien <br />Federal ID Number <br />473322665 <br />Social Security Number <br />0 County Clerk XXX -XX -2096 <br />Revenue Agent <br />rile <br />Revenue Senior Agent <br />Title <br />County <br />No. 0597 <br />PLEASE DO NOT WRITE IN THIS SPACE <br />1 /•1 <br />J J <br />NE See of Sl.ir .7 h., a 0.1e - UCC STL <br />r <br />99177913 -3 Pga: I <br />AVENDANO JOSE T. <br />F(1.d; 05/02/20117 09:59 AM <br />Spouse's Social Security Number <br />[}corrected MALL <br />Tax • ayer Name and Mailing Address <br />JOSE 1_ AVENDANO <br />1603 HOPE ST <br />GRAND ISLAND NE 68801 <br />64.00 <br />Prepaid Wireless <br />Prepaid Wireless_ <br />Sales <br />Saks <br />Tax Program <br />Tax Period <br />04/01/2015 - 07/31/2015 <br />09/01/2015 - 04/30/2016 <br />05/01/2015 - 07/31/2015 <br />09/01/2015 - 04/30/2016 07/25/2016 <br />Date of <br />Assessment <br />• 10/01/2015 <br />07/25/2016 <br />10/01/2015 <br />Tax <br />.00 <br />760.00 <br />Penalty <br />100.00 <br />206.40 <br />50.00 <br />276.00 <br />Interest Costs <br />— - -- -.00 <br />2.32 .00 <br />_62 .00 <br />27.33 .00 <br />Total <br />Total Due <br />— - 100 -10 <br />272.72 <br />50.62 <br />1,063.33 <br />1,486.77 <br />I certify that the Nebraska Department of Revenue has complied with the laws of the State of Nebraska In determining the amount shown to be due. <br />and that the yet has (ailed to pay th :. ou due after demand.This Notice of State Tax Lien Is an effective lien and serves to continue the priority of <br />04/24/2017 _ 402 -471 -6067 <br />Data <br />phone Number <br />LL J 1 7 <br />Dale <br />.4494 Rev. 8-2013 Supersedes 4-448 -1074 Nev. 2 -2002 <br />V <br />