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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 />2013 <br />06/02/2017 <br />$303.91 <br />$15.20 <br />$33.12 <br />352.23 <br />Total <br />$352.23 <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 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 />PLEASE DO NOT WRITE IN THIS SPACE <br />Nebraska ID Number <br />41813421 <br />Federal ID Number <br />Lien Serial Number <br />11798411 <br />Uen Filed With: <br />Social Security Number <br />XXX -XX -4264 <br />Spouse's Social Security Number <br />XXX -XX -6608 <br />F7 Register of Deeds ❑ County Clerk <br />Date of Lien <br />December 01, 2017 <br />Lien Type: <br />❑Corrected <br />County <br />HALL <br />Li original ■ Continuation <br />Dec, 5, 2517 3:58F111 NE Secretary of State — UCC <br />Net Naha 0epertm of <br />REVENUE <br />Business Name and Location Address <br />Notice of State Tax Lien <br />NE S•c of Slai• Bohn A e•1• <br />ucc ESL <br />I1'I <br />89178 ®26 <br />PSIS : 1 <br />GROSSART BRANDON <br />fil4d: 12/0512011 09:26 AM <br />Taxpayer Name and Mailing Address <br />BRANDON J GROSSART <br />AMBER D GROSSART <br />2004 E 7 ST <br />GRAND ISLAND NE 68801 <br />No. 2797 P. 2 <br />2O1— 38 <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 />that the taxpayer has hared y the amount due aft m <br />alter deand.This Notice at State Tax lien is an effective Fen and serves to continue the priority of <br />e ast _ _ in est in the affects open i el theta . =yer. <br />Revenue Agent 12/01/2017 (402 ),471 -5928 <br />Title Date Phone Number <br />Revenue Supervisor 12/01/2017 <br />Authorized Signature Title Dale <br />4-494-1974 ABV. 8-2013 Supersedes 4-949-1974 Rev. 2-2002 <br />