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Tax Program Tax Period Date of Assessment Tax Penalty Interest Costs Total Due Individual 2016 06/27/2017 $793.00 $39.65 $15.19 tj original ❑ Continuation 847.84 Total $847.84 This Notice of State Tax Lien is issued by the Nebraska Department of Revenue for unpaid taxes administered by the Tax Commissioner. Taxes, including penalties, interest, and costs, which are shown below, are due from the taxpayer and remain unpaid after demand.These taxes are a lien for all property located in the county and rights to property owned by the taxpayer or acquired before the expiration of this Iien.This lien will expire and become unenforceable 10 years after the date of recording if no continuation statement is recorded on or prior to the expiration of the previous lien or continuation statement. PLEASE DO NOT WRITE IN THIS SPACE Nebraska ID Number 99299291 Federal ID Number Lien Serial Number 11798451 Lien Flied With: Social Security Number XXX-XX-4280 Spouse's Social Security Number pi Register of Deeds D County Clerk Oats of lien December 04, 2017 Lien Type: County HALL tj original ❑ Continuation • Corrected Dec, 6. 2517 3:36FM NE Secretary of State — UCC Neb.Baka Dap�rtment df REVENUE Notice of State Tax Lien NE Sac cf S4ats Jahn a Gtla - uCC 3rL I, I 9917802668 —A Pas: 1 CORTEZ CRUZ MRTIRS Filed: 12/06/2017 08:56 AM 2� i'A82tig Business Name and Location Address Taxpayer Name and Mailing Address CRUZ MATIAS CORTEZ 1311 N PARK AVE GRAND ISLAND NE 68803 Revenue Agent Title Revenue Supervisor Title Sign here Pre I certify that the Nebraska Department of Revenue has compiled with the laws at the State of Nebraska in determining the amount shown to be due, a • hat the taxpayer has failed to • the amount due after demand. This Notice of Stale Tex Uen la an effective lien and serves to continue the priority of te's interest in the affec _ party the taxpayer. A thorized Signature (402)471 -5928 Phone Number 12/04/2017 Date 4494 -1974 Rev, 9.2419 Supmades 4.e494979 Flay, 2.2002