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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 />Sales <br />04/01/2016 - 05/31/2016 <br />06/03/2016 <br />974,43 <br />246.20 <br />6125 <br />40.00 <br />1,321-88 <br />Withholding <br />04/01/2016 - 06/30/2016 <br />08/30/2016 <br />.00 <br />4.93 <br />.19 <br />.00 <br />5.12 <br />Total <br />1,327.00 <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.Thls 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 />. <br />Nebraska ID Number <br />10684611 <br />f=ederal ID Number <br />454914615 <br />Len Serial Number <br />11798615 <br />Lien Filed With: <br />® Register of Coeds ❑ County Clerk <br />Social Security Number <br />XXX_XX_3192 <br />Spouse's Social Security Number <br />Date of Lien <br />December 18, 2017 <br />Olen Type: <br />® ori ['Continuation 0Corrected <br />County <br />HALL <br />Jan.17. 2013 3:01FM NE Secretary of State — UCC <br />Nebraska Department of <br />REVENUE <br />sign <br />here <br />Business Name and Location Address <br />the SLterest In the affected prod • lne taxpayer. <br />i <br />D !' L (I S..�a{.,I�. <br />pare gnalure <br />Authorized Signature <br />Notice of State Tax Lien <br />Title <br />No. J27V <br />NE S. of 5+.48 J.., h p 6.1. - UCC <br />9918804614 -7 <br />BANDASPCK KHfttl <br />Filed: 01/17/2018 08:55 All <br />1 <br />II <br />Ij <br />! il <br />2.0180032 <br />ITL <br />Pas 1 <br />Taxpayer Name and Mailing Address <br />KHAM BANDASACK <br />1416 W. 1ST <br />GRAND ISLAND NE 68801 <br />I certify that the Nebraska Department of Revenue has complied with the laws 01 the State at Nebraska in determining the amount shown to be due, <br />and T I = payer has failed 10 pay the a • um due after demand. This Notice of State Tax Uen Is an effective Iles ane serves to continue the priority of <br />Revenue Agent 12/11/2017 <br />Title Date <br />Revenue Senior Agent <br />402- 471 -5711 <br />Phone Number <br />Dale <br />4- 484 -1974 Rev 8-2019 supersedes 4-949-1974 Rev. 2-2002 <br />A.t. <br />