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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 />07/01/2014 - 06/30/2016 <br />05/12/2017 <br />107.75 <br />60.78 <br />3.75 <br />.00 <br />172.28 <br />Sales <br />07/0I/2015 - 08/02/2016 <br />05/12/2017 <br />21,334.73 <br />3,878.97 <br />804.27 <br />.00 <br />26,017.97 <br />Withholding <br />01/01/2016 - 08/02/2016 <br />05/12/2017 <br />970.53 <br />194.83 <br />25.33 <br />.00 <br />1,190.69 <br />Total <br />27,380.94 <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 />PLEASE DO NOT WRITE IN THIS SPACE <br />Nebraska ID Number <br />11872314 <br />Federal 10 Number <br />471396107 <br />Lien Serial Number <br />11788779 <br />Lien Filed with; <br />Social Security Number <br />XXX-XX-1741 <br />Spouses Social Security Number <br />ri Register of Deeds [, County Clerk <br />Date of Lien <br />June 7, 2017 <br />Lien Type: <br />0Corrected <br />County <br />HALL <br />Ki Original ❑ Continuation <br />Jun. 14. 2017 3:02FM NE Secr etary of State — UCC <br />IttES/A.----Z-- <br />Nebraska Department of <br />REVENUE <br />sign <br />here <br />Business Name and Location Address <br />201703974 <br />Notice of State Tax Lien <br />Revenue Agent <br />Title <br />Revenue Senior Agent <br />ALEX ADAME <br />1014 W WASHINGTON ST <br />GRAND ISLAND NE 68801 <br />No. 1053 F. 10/10 <br />RE Sec a{ sit {. lot.n A C. - UCC STL <br />9917793557 -9 Pgs <br />ADAM ALEX <br />Filed: ee114J2 017 11 :40 1:1P1 <br />Taxpayer Name and Mailing Address <br />I certify that the Nebraska Oeparlment of Revenue has complied with the laws of the State of Nebraska In determining the amount shown to be due. <br />and that th= yer has tailed to pay count due after demand. This Notice of State Tax Lien is an effective lien and serves to continue the priority of <br />the that <br />in the affected .. .per . of the taxpayer. <br />06/12/2017 402-471-6067 <br />Date Phone Number <br />ID / A f7 <br />Aeihorized Signature Title Dale <br />4.494 -1974 Rev. 8-2013 Supersedes 4 -949 -1974 Rev. 2.200 <br />