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Seri. S. 2010 4'03PM N E Secretary .t State — UCC <br />201805831 <br />N ewe ska Department or <br />REVENUE <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 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 />Nebraska ID Number <br />35003871 <br />Lien Serial Number <br />11812782 <br />sign <br />here <br />type: <br />® Original <br />Lien <br />Date ol Lien <br />August 23, 2018 <br />Business Name and Location Address <br />Notice of State Tax Lien <br />Lien Filed With: <br />® Register of Deeds ['County Clark <br />Continuation <br />Federal 0 Number <br />Social Security Number <br />XXX -XX -5670 <br />WE 5oc of Ifni. John G Sale - tl[C STL <br />PLEASE DO NOT WRITE IN THIS SPACE <br />9918818896 -9 Pes: <br />MEDBERY MICHAEL L <br />Fitad: BA/05/2018 11:3D AM <br />PLEASE RETURN TO: <br />NEBRASKA DEPT OF REVENUE <br />PO BOX 94609 <br />LINCOLN NE 685094609 <br />fl Corrected <br />County <br />HALL <br />MICHAEL L MEDBERY <br />511 WALDO AVE <br />GRAND ISLAND NE 68803 <br />No. 5100 P. 2!2 <br />Taxpayer Name and Mailing Address <br />Spouse's Social Security Number <br />Tax Program <br />Individual <br />Tax Period <br />2015 <br />r Date of <br />Assessment <br />05/24/2016 <br />Tax <br />$524.00 <br />Penalty <br />$42.75 <br />Interest Costs <br />$37.04 <br />Total <br />Total Due <br />603.79 <br />$603.79 <br />I certify that the Nebraska Department of Revenue has compiled with the laws of the State of Nebraska in determining the amount shown to be due. <br />and that the taxpayer has faile• ay the a ' nt due after demand. This NOL1ce of State Tax Lien is an effective lien and serves to continue the priority ol <br />the State's interest in the elle 'i iia i1, of tti . <br />Revenue Agent 08/23/2018 (308)632 -1206 <br />Title Cate Phone Number <br />Revenue Supervisor 08/23/2018 <br />Title Date <br />4454 -1974 Rev. 8-2D13 Superset e- 949.1974 RrrL 2-2002 <br />