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Tax <br />Program <br />Tax Period <br />Date of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costs <br />Total Due <br />Individual <br />2014 <br />03/21/2016 <br />326.23 <br />16.45 <br />21.37 <br />364.05 <br />Total <br />$364.05 <br />_!un.21. 2017 3:22FM NE Secretary of !.State — UCC <br />Nebraska Department or <br />REVENUE <br />Nebraska ID Number <br />95848371 <br />Lien Serial Number <br />11789665 <br />Date of Lien <br />06/15/2017 <br />r <br />sign <br />here <br />Business Name and Location Address <br />Authorized Signature <br />201704146 <br />Notice of State Tax Lien <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 properly 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 11 no <br />continuation statement Is recorded on or prior to the expiration of <br />the previous Ilen or continuation statement <br />Lion Filed With: <br />Register of Peea* L J County Clerk <br />Federal ID Number <br />Social Security Number <br />XXX -XX -8211 <br />Lien type; <br />® Orhgnaf El Continuation LJ Corrected <br />JUSTIN ANDERSON <br />339 1/2 S OAK ST <br />GRAND ISLAND NE 68801 <br />I certify that the Nebraska Departrnenl Of Revenue has complied tahth the laws of the State of Nebraska In determining the amount shown to be due, <br />and mat the taxpayer has fatted to pay the amount due after demand. This Notice o1 Slate Tax Lien Is an effective nen and serves to continue the priority of <br />the State's interest in the affected property of the taxpayer. <br />refs Signature <br />Revenue Agent <br />PLEASE DO NOT WHITE IN THIS SPACE <br />County <br />HALL <br />Taxpayer Name and Mailing Address <br />No. 1125 P. 3, <br />Na tee of &Sikh. John II O.re • U[[ ST <br />1 <br />9917783884 -2 Pas: <br />ANDERSON JUSTIN <br />Filed 05/21/2017 70 :05 AM <br />Spouse's Social Security Number <br />06/15/2017 (402)471 -5712 <br />Tide Date Phone Number <br />Revenue Supervisor 06/15/2017 <br />Title Dale <br />4-094 -1874 Rev. 9.2013 Supersodea 4-041;1874 Rey. 2 -2002 <br />