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Tax Program <br />Tax Period <br />Date of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costs <br />Toter Due <br />Individual <br />2011 <br />08/06/2017 <br />$4,234.00 <br />$1,058.50 <br />$814.79 <br />6,107.29 <br />Individual <br />2012 <br />08/06/2017 <br />$695.00 <br />$173.75 <br />$103.00 <br />971.75 <br />Individual <br />2015 <br />08/06/2017 <br />$599.00 <br />$149 -75 <br />$34.81 <br />783 -56 <br />Total <br />$7,662.60 <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 Ilen 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 WHITE INTHIS SPACE <br />Nebraska ID Number <br />99504030 <br />Federal ID Number <br />Lien Serial Number <br />11804009 <br />Lien Fled With: <br />Social Security Number <br />XXX -XX -3740 <br />Spouge'S Social Security Number <br />Register of Deede • Cour.ly clerk <br />Date of Lien <br />March 23, 2018 <br />Lien Type: <br />gig Original ❑ Contlnt,ation <br />County <br />HALL <br />■ Corrected <br />Mar, 26. 2016 2:51R <br />Nebraska Department of <br />REVENUE <br />Sign <br />here <br />Business Name and Location Address <br />NE Secretary of State — UCC <br />repay - .. Signature <br />Autha !zed Signature <br />Notice of State Tax Lien <br />2O180187i) 2/2 <br />NE Sec of Stake John A Oak <br />89188081113-5 Pgs <br />SHAFFER DAVID <br />Filed; 03/26/2015 11:46 AM <br />DAVID SHAFFER <br />2126 NORTH PARK AVE <br />GRAND ISLAND NE 68803 <br />Taxpayer Name and Mailing Address <br />f °edify 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 />and that the taxpayer has fa = to pay the amount due after demand. This Notice of Stale Tax lien Is an effective Ilen and serves to continue the priority of <br />the SIa interest in the a ' -cted property of the <br />1 <br />Revenue Agent 03/23/2018 (402)471 -6043 <br />Tide Date Phone Number <br />Revenue Supervisor 03/23/2018 <br />Tide Date <br />4 - 494 - 1974 Mev. 8.2010 SuperseOes 4-949-1974 Hev. 2 - 2002 <br />'04 <br />