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Tax Program <br />Tax Period <br />A Date nt <br />Tax <br />Penalty <br />Interest <br />Costs <br />Total Due <br />Individual <br />2015 <br />11/04/2016 <br />1,083.00 <br />66.72 <br />39.52 <br />1,189.24 <br />Total <br />$1,189.24 <br />Jul, 6. 2017 3:11PM NE Secretary of State — .UCC <br />Nebre5ke Department or <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.Thls 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 />39983781 <br />Lien Serial Number <br />11790488 <br />Date of Lien <br />07/03/2017 <br />lien Fllel With: <br />Register ol Deeds 0 County Clerk <br />Lien Type: <br />© Original 0 Continuation <br />Business Name and Location Address <br />sign <br />here <br />Authorized Signature <br />201704525 <br />Notice of State Tax Lien <br />rule <br />PLEASE DO NOT WRITE IN THIS SPACE <br />Federal D Number <br />Social Security Number <br />XXX -XX -3623 <br />°Corrected <br />Taxpayer Name and Mailing Address <br />NICKOLAS J BLATH <br />1721 LOUISE <br />GRAND ISLAND NE 68803 <br />County <br />HALL <br />p n <br />Nc. 13�,1u <br />NE Sete of 5i• e Je.n A Graf, - VGG sTL <br />9917794868 -5 <br />BLATH NICKOLAS 3 <br />Filed: 07/06/2817 09:16 AM <br />Spouse% Social Security Number <br />!certify that the Nebraska Department of Revenue has complied with the laws of the Stale of Nebraska in determining the amount shown to be due, <br />and that the laxpay as failed to pay the amount due after demand. this Notice ol State Tax Lien is an effective lien and serves to continue the priority of <br />the S . ABMs the affected property of the taxpayer, <br />Revenue Agent <br />Title <br />Revenue Supervisor <br />07103/2017 }402)471 -6043 <br />Dale Phone Number <br />07/03/2017 <br />Date <br />4194 - 1974 Rev. 9-2017 Supersedes 4 949 - 197a Rev. 2.2002 <br />Pea <br />