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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 />Individual <br />2011 <br />04/14/2015 <br />$215.00 <br />$10.75 <br />$38.60 <br />Q Corrected <br />264.35 <br />Total <br />$264.35 <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 data 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 />` <br />Nebraska ID Number <br />95883878 <br />Federal ID Number <br />Lien Serial Number <br />11795834 <br />Lien Filed With: <br />Social Security Number <br />XXx_XX -1393 <br />Spouse's Social Security Number <br />ri Register of Deeds ° County Clerk <br />Date of Lien <br />October 17. 2017 <br />Lien Type: <br />Q Corrected <br />County <br />HALL <br />1 <br />l Original 1 Continuation <br />Oct. 19. 2017 4:02FM NE Secretary of State — UCC No.2333 <br />Nebraska Department of <br />REVENUE <br />sign <br />here <br />Business Name and Location Address <br />201707122 <br />Notice of State Tax Lien <br />Tax <br />er Name and Hi in <br />CARLOS A OCHOA <br />319 S WALNUT ST APT 110 <br />GRAND ISLAND NE 68801 <br />11E S.n of S4.4e Jahn C 5.1. - Uc[ STL <br />111111 II 11 <br />9927 800129 --4 P ge : I <br />OCHOA CARLOS A <br />Filed; 10/19/2o17 02 :07 P11 <br />ress <br />I 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 that the taxpayer has tailed to pay the amount due alter demend. This Notice of State Tax Lien is an effective lien and senues to continue the priority of <br />the tale's interest in the affected property of the taxpayer. <br />Revenue Agent 10/17/2017 (4021471 -5713 <br />Title Date Phone Number <br />Revenue Supervisor 10/17/2017 <br />Title Date <br />4- 4941974 Rey. B-2013 Supersedes 4.2•9 - 1974 Rev. 2 -2002 <br />1 <br />