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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 />12/08/2015 <br />$311.06 <br />$77.77 <br />$55.88 <br />444.71 <br />Total <br />$444.71 <br />• Oct,20. 2017 3:12PM - NE Secretary of State — UCC <br />Nebraska Department of <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 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 lien or continuation statement. <br />Nebraska 10 Number <br />34671617 <br />Lien Serial Number <br />11795885 <br />Date of Lien <br />October 18, 2017 <br />sign <br />IC '1; <br />lip.. A <br />here Prep <br />es Signature <br />Notice of State Tax Lien <br />Lien Filed With: <br />al Register of Deed. ❑ County Clerk <br />Lien Type: <br />® original <br />Business Name and Location Address <br />Continuation <br />Federal ID Number <br />Social Security Number <br />XXX -XX -7164 <br />NE I. of SL,4m John R 6.1. - EEC 4-74., <br />11 1111 <br />9917800138 -3 Pee: 1 <br />NIELSEN STACEY N <br />Filed: 1012 0/2017 0A:33 AM <br />PLEASE DO NOT WRITE INTHIS SPACE <br />2 tic '1 <br />Spouse's Social Security Number <br />County <br />LI Corrected HALL <br />Taxpayer Name and Mailin ' Address <br />STACEY W NIELSEN <br />PO BOX 341 <br />WOOD RIVER NE 68883 <br />certify that the Nebraska Department Of Revenue has complied with the laws of me State of Nebraska in determining Me amount Shown to be due. <br />and that the taxpayer has failed to pay the amount due after demand. This Notice of Stale Tax Llen Is an effective lien and serves to continue the prority of <br />he Slate's Interest in the affected property of the taxpayer. <br />Revenue Agent 10/18/2017 (402)471-5712 <br />Tnle Date Phone Number <br />Revenue Supervisor 10/18/2017 <br />A thonna Signature Title Date <br />4494-197/ Rev. a -2019 Supersede(' 4449 -1971 Rev. 2.7002 <br />.1 <br />