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Tax Program Tax Period Date of Assessment Tax Penalty Interest Costs Total Due Withholding 10/01/2015 - 12/31/2015 04/11/2016 .00 145.22 .00 .00 145.22 Withholding 10/01/2016 - 12/31/2016 .06/18/2017 300.00 75.00 8.62 .00 383.62 Withholding 07/01/2016 - 09/30/2016 06/18/2017 300.00 105.00 10.89 .00 415.89 Withholding 01/01/2016 - 03/31/2016 06/18/2017 300.00 105.00 15.43 .00 420.43 Withholding 04/01/2016 - 06/30/2016 06/18/2017 300.00 105.00 13.16 .00 418.16 Total 1,783.32 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 lien.This Hen 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 9713220 Federal ID Number 204173143 Lien Serial Number 1 y 899416 Lien Flied Wth: Social Smutty Number - XXX -XX -7790 Spouse's Social Security Number XXX-XX-2666 C7 Register of Deeds • County Clerk Date of Lien January 16, 2018 Lien Type: Corrected County HALL E1 Original Continuation Feb. 1. 2018 3:34FV1 NE Secretary o f State — UCC \i/) • Nebraska Department of • REVENUE sign here Business Name and Location Address SIMMONS ELECTRIC INC 1212 SAGEWOOD AVE GRAND ISLAND NE 68803 Authorized Signature Notice of State Tax Lien Revenue Agent Title Revenue Senior Agent Title CARLOS SIMMONS 1212 SAGEWOOD AVE GRAND ISLAND NE 68803 2 013860 068g WE sae of 51a4o John II Taxpayer Name and Mailing Address N Sole - 'JCL Sri Pes : 1 99!88 ®5528 -5 SIMMONS CARLOS Filed: 02/01/2018 03:16 Pill I certify that the Nebraska Department of Revenue hae compiled with the laws of the Stale of Nebraska In determining the amount shown to be due, end that the taxpayer has tailed to pay the amount due after demand. This Notice or State Tax Lien is an effective lien end serves to continue the priority of the Slate's interest in the affected property of the taxpayer. 01/09/2018 402 - 471 -5787 Dale Prone Num Date 4-494 -1974 Rau 8-2013 Supersede; 4.949 - 1974 Rev. 2 -2002