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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 />Litter Fee <br />07/01/2015 - 06/30/2016 <br />05/06/2017 <br />.00 <br />25.00 <br />.00 <br />.00 <br />25.00 <br />Sales <br />01/01 /2016 - 12/31/2016 <br />05/06/2017 <br />500.00 <br />100.00 <br />5.46 <br />.00 <br />605.46 <br />Total <br />630.46 <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 IN THIS SPACE <br />Nebraska ID Number <br />12135372 �_. <br />Federal ID Number <br />474983449 <br />Lien Serial Number <br />11788969 <br />Lien Filed With: <br />Social Security Number <br />XXX-XX-0682 <br />Spouse's Social Security Number <br />pi Register of Deeds ❑ County Clerk <br />Date of Lien <br />June 2, 2017 <br />Lien Type: <br />® Original ❑ Conllnuation ❑ Corrected <br />County <br />BALL <br />Nebraska Department of <br />REVENUE <br />sign <br />here <br />Jun. 7. 2017 3 u3FM NE Se_r_tary . f State — UCC 0970 F. 3 <br />Business Name and Location Address <br />horized Signature <br />Notice of State Tax Lien <br />Taxpayer Name and Ma <br />RAMIRO Y LA ROSA PEREZ <br />1021 WEST LOUISE ST <br />GRAND ISLAND NE 68801 <br />201703814 <br />NE S.c of S{.lie John p Gala - UGC 5TL <br />9917793145 -8 Pas; 1 <br />LA RASA PEREZ RAAIRO Y <br />Filed: 00/0712017 02:29 PM <br />ress <br />!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 Thal the taxpayer has failed to pay Me amount due alter demand.Trils Notice of State Tax Uan Is an effective lien and serves to continue the priority of <br />the S,fa interest In the affected propert of the taxpayer. <br />Revenue Senior Agent 06/02/2017 402- 471 -5727 <br />Title Dete Phone Number <br />Revenue Senior Agent (® <br />Tills Dale <br />a - 4941974 Rev. a -2013 Supersedes 4-944.1974 Rev. 2 -2002 <br />