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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 />2012 <br />10/10/2017 <br />$78.00 <br />$19.50 <br />$11.64 <br />109.14 <br />Individual <br />2013 <br />10/10/2017 <br />$175.00 <br />$43.75 <br />$20.87 <br />239.62 <br />Individual <br />2014 <br />09/13/2017 <br />$137.00 <br />$34.25 <br />$12.23 <br />183.48 <br />Individual <br />. 2015 <br />08/16/2017 <br />$101.00 <br />$25.25 <br />$5.98 <br />132.23 <br />Total <br />$664.47 <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 Ilen.This Hen 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 10 Number <br />46883258 <br />federal Ci Number <br />Lien Serial Number <br />11804710 <br />Lien Filed With; <br />Social Security Number <br />XXX -XX -2733 <br />Spouse's Social Security Number <br />[] Register of Deeds • County Clerk <br />Dale of Lien <br />April 05, 2018 <br />Lien 10>e: <br />]Corrected <br />County <br />HALL <br />j original ■ Continuation <br />Apr, 10. 2018 3:18PM NE Secretary of State — UCC <br />Nebraska Department of <br />REVENUE <br />sign <br />here <br />Business Name and Location Address <br />Auth rized Signature <br />Notice of State Tax Lien <br />Title <br />No. 4020 F. 2 <br />201802276 <br />NI 1 of 54.4a John • 6e 1e - UCC 5n <br />I <br />A 1 nI Plat: 1 <br />BERNASE DOAINGO BAUTISTA <br />Filed: 04/10/2015 09:44 API <br />Taxpayer Name and Mailing Address <br />DOMINGO BAUTISTA BERNABE <br />612 N VINE <br />GRAND ISLAND NE 68801 <br />I certify that the Nebraska Department of Revenue has complied with the laws or the State of Nebraska In determining the amount shown to be due, <br />that the taxpayer has failed pay the amount due after demand, This Notice of State Tau Lien iti an effective lien and serves to continue the priority of <br />Sla ='s interest in the Sffe - - ope of the taxpayer. <br />Revenue Aylent 04/05/2018 (402)471 -5928 <br />Title Dale Phone Number <br />Revenue Supervisor 04/05/2018 <br />Date <br />4 naV. 8-2019 eupersodes 4949.1974 Rev. 2 -2002 <br />