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Tax Program Tax Period Date of Assessment Tax Penalty Interest Costs Total Due Sales 08/01/2015 - 09/30/2015 12/01/2015 237.80 28.13 31.83 .00 297.76 Sales 11/01/2015 - 01/31/2016 04/01/2016 .00 75.00 1.61 .00 76,61 Sales 04/01/2016 - 05/31/2016 07/01/2016 215.59 50.00 13.84 .00 279.43 Sales 06/01/2016 - 09/30/2016 12/01/2016 .00 75.00 1.72 .00 76.72 Sales 11/01/2016 - 07/31/2017 11/12/2017 1,130.32 400.50 33.36 .00 1,564.18 Sales 08/01/2017 - 11/30/2017 01/02/2018 252 -18 75.00 3.90 .00 331.08 Sales 12/01/2014 - 07/31/2015 .00 385.73 57.69 .00 443.42 Total 3.069.20 2 1 NESet"�O�, 416Jahn RF• L II CC ST 1111 .1111 991881 0183 -5 • Pes: Upon filing of this lien, and , ItedLFb4 "23!2010 12:52 Prl further notice, your property may be seized to satisfy this lien. Apr, 23. 2018 3:25FM NE Secretary of State - UGC NebrssKa Dopartment of REVENUE 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. Nebraska ID Number 11185856 Lien Serial Number 11805390 Date of Lien April 20, 2018 TIM BOTTOLFSON 113 LYNN LN GRAND ISLAND NE 68801 sign here Notice of State Tax Lien Lien Flied With: Register of Creeds [1 County Clerk Business Name and Location Address A prized Signature Title PLEASE LIU NV _ TRITE1NTRis 31111.1 Federal 0 Number Social Security Number XXX-XX-9887 Lien Type: original fl Continuation Corrected county HALL TIM BOTTOLPSON 113 LYNN LN GRAND ISLAND NE 68801 Spouse's Social Scourtty Number Taxpayer Name and Mailing Address 1 tartly that the Nebraska Dap= ment o1 Revenue has complied with the laws of the State of Nebraska in delerminfng the amount shown to be due, and that taxpayer has failed to : y the amount due after demand, This Notice of Stale Tax Lien Is an effective lien and serves to condnue the priority of the Ste erect in the affe -j. ,..arty of the Taxpayer. Revenue Agent 04/20/2018 402- 471 -5789 Title Date Phone Numb Revenue Senior Agent `7 sZD1 Date 4- 494 -1974 Rev. 5-2019 Supersedes 1.944.1874 Rev. 2 -2002 IY