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Aug. 20. 2ii13 38PM NE = _ rotary f Stat . Nc. U819 F. 3/ V JJV � lsLP Jahn n pale - L[[ST Ha Sew et s P9s: 1 "� SERVICES 1 991881rp9uTSomoim SERVICES Ft ter2¢07019 09- airve td eka Department of REVENUE Notice of State Tax Lien This Notice of State Tax Lien is issued by the Nebraska PLEASE DO NOT WRITE IN THIS SPACE 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.Thls 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 Federal 10 Number 9221042 900068518 Lien Serial Number Lien Filed With; Social Security Number Spouse's Social Security Number 11811305 ®Register of Deeds 0 Courtly Clerk Date of Lien Lien type: County August 9,2018 rE Original 0 Conilnuation ❑Corrected HALL Business Name and Location Address _ Taxpayer Name and MaIIIng Address M PERSONAL AUTOMOTIVE SERVICES INC 2404 W LINCOLN HIGHWAY • GRAND ISLAND NE 68803 Tax Program Tax Period Date of Tax Penalty Interest Costs Total Due Assessment Sales 08/0112016-03/31/2017 05/01/2017 33,007.63 2,380.33 1,648.66 .00 37,036.62 Sales 01/01/2016-07/31/2016 06/25/2018 .00 .00 119-81 .00, 119.81 Sales - 02/01/2015 -12/31/2015 06/25/2018 472.31 82.98 76/6 .00 632.05 Sales 01/01/2014- 12/31/2014 06/25/2018 54.65 _00 7.31_ .00 61.96 Withholding 07/01/2016-12/31/2016 05/10/2017 3,545.84 654.75 21113 .00 4,415.72 Withholding 01/01/2017-03/31/2017 06/28/2017 1,287.47 462.44 97.51 .00 1,847.42 Withholding 04/01/2017-06/30/2017 08/10/2017 4,745.18 237.26 145.87 .00 5,128.31 Withholding 07/01/2017-09/30/2017 11/13/2017 3,276.05 163.80 75.93 200.00 3,715.78 Withholding 10/01/2017- 12/31/2017 03/28/2018 5,048.29 504.83 78.84 .00 5,631.96 Total 58,589.63 I certify that the Nebraska Department of Revenue has complied with the laws of the State of Nebraska In determining the amount shown to be due, and that th: _ ,ayer has tailed to pay the a .unt due i.;-r demand.This Notice of State Tax Lien is an effective lien and serves to continue the priority of the Sl to crest In the affected pro. rly• the taxp-' r. sign apt' / A.. / •Itt /,� _-_ Revenue Agent 08/02/2018 402-471-5711 here 77= -r:'s Signature or'� Title Dale Phone Number J JI!_% r , / Revenue Senior Agent ?-/ -/P - thorized Signature Title Date 4-494-1974 Rev.9-2013 Supersedes 4-9g9-t9/4 Rev.ft,;\