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T aY <br />Program <br />Tax Period <br />Date of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costa <br />Total Due <br />Individual <br />2015 <br />05108/2017 <br />446.00 <br />' 22.30 <br />18.85 <br />487.15 <br />Total <br />$487.15 <br />. Sep. 15. 2017 2:30FM <br />PLEASE RETURN TO: <br />NEBRASKA DEPT OF REVENUE <br />PO BOX 94609 <br />LINCOLN NE 685094609 <br />Nebraelte Department al <br />REVENUE <br />1 <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 area Tien for all property located <br />in the county and rights to property owned by the taxpayer or <br />acquired before the expiration of thls 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 Den or continuation statement. <br />Nebraska ID Number <br />96588195 <br />lien Serial Number <br />11793686 <br />Lien Filed With: <br />© Register of Deeds ❑ County Clerk <br />Dale of Uen Uen Type: <br />0911112017 NI Original <br />Business Name and Location Address <br />Sign <br />here <br />NE Secretary of State — UCC <br />Prepay <br />Authorized Sig <br />Notice of State Tax Lien <br />0 Continuation <br />Tllle <br />PLEASE 00 NOT WRITE IN THIS SPACE <br />Federal ID Number <br />Social Security Number <br />XXX -XX -0738 <br />0 Corroded <br />JOSE POL VELASQUEZ <br />409 W 5TH ST <br />GRAND ISLAND NE 68801 <br />Revenue Senior Agent <br />Thle <br />Revenue Supervisor <br />201/06154 22 <br />Taxpayer Name and Mailing Address <br />NE lee of Sfate Jorn A A.le - UCC ITL <br />i <br />9517798048 -5 Pgs, 1 <br />POL VELRSQUEZ JOSE <br />Filed: 0 9/1S/2017 11:47 P11 <br />Sponse %Social Security Number <br />County <br />HALL <br />I certify that the Nebraska Department of Revenue has complied wlih (he taws of the State of Nebraska in dalermIn' g the amount shown to be due, <br />and that the taxpayer has farted to pay the amount due after demand.This Notice 01 State Tax Lien Is an effective ben and serves (0 continue the priority of <br />the Slete'6lntarest k1(1* affected properly of the taxpayer <br />09111 /2017 <br />Date <br />(308)632 -1205 <br />Phone Number <br />09111/2017 <br />pale <br />6401-1874 Rev 0.013 Supersedes 4- 0494974 Rau. 2.2002 <br />