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h <br />it <br />-'1 <br />R <br />r <br />4 <br />nnhraska <br />department <br />of rx�emre <br />Notice of State Tax Lien <br />*Read Instructions an reverse side <br />Lien Serial Number <br />Lien Type <br />pate <br />Social Security Number <br />Penalty <br />Interest <br />Additions <br />OrI9111a1 <br />21 <br />01-01`89 thru <br />9/06/27' <br />© Renewal <br />6 -26.89 <br />89e- 1033193 <br />3,1 <br />ii <br />Nebraska I.D. NO.� <br />County --- <br />Lienn Filed With <br />SpOUfe's Social Security <br />5538524 <br />Hall <br />Register of Oeeds <br />Number <br />VV <br />(� County Clerk <br />BUSINESS NAME AND LOCATION ADDRESS <br />TAXPAYER NAME AND MAILING ADDRESS <br />Business Name <br />Name m� <br />The Roosevelt, Inc. <br />Street Address <br />Street or Other Mailing Address <br />321 W. 2nd Street <br />City <br />State <br />210 Code <br />City <br />State Zip Code <br />5 <br />brand Island, <br />NE 68801 <br />This Notice of State Tax Lien is Issued by the Nebraska Department of Revenue for unpaid tares pursuant to the <br />revenue laws of the state of Nebraska. Notice is hereby given that taxes including penalties and interest, which arc <br />shown below, are due from the taxpayer specified above and remain unpaid after demand. These fires constitute <br />a Ben In the county for real and personal property belonging to the taxpayer or hereafter acquired. <br />Tax <br />Cateaofy <br />Nu1nMf <br />Tax PeHod <br />Oats of <br />Assessment <br />Amount of Tax <br />Penalty <br />Interest <br />Additions <br />Balance of <br />Aseesament Oux <br />21 <br />01-01`89 thru <br />4.11 <br />211-33 <br />TOTAL <br />5 <br />I hereby certify that the Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in the deter- <br />+' i •mination of the amount shown to be due, and the taxpayer has failed to pay the amount.dus after demand. If this Notice of State Tax <br />_;••'j :. Lien Is an Ion of an attire Reqy serves to continue the priority of the state's interest. in the affected property of the taxpayer. <br />ra! A TaYnaugt*c Sarvires Snot- fat•�lSt <br />ah�re o r'ss ure :�` Tttie —° r Date <br />+, 5` ■ ligpip Ag1pnt quptar1i]SDr o?� <br />-. Au oriied Signature , TttIR Date, <br />FOR COUNTY OFFICIAL'S USE. <br />r <br />NEBAASiKA DEPARTMENT OF REVENUE -White and Goldenrod Copies 7AXPAVBA -Pink Copy COUNTY OFFICE — Canary Copy <br />4-49 •74 Rev. 9 88 „ . <br />THE ATTACM.11ftCi(S) (V Th#.,:YeIEN (OR TaII 11IMTION) IS (ARE) TO St FILED GMLT <br />. DEEDS. <br />THE DOdbMENT(S) IS (ARE)'NOT TO BE FORWARDED TO THE COUNTY CLERK. <br />DISTRIBUTION OF COPIES: <br />WHITE: TO BE VALIDATED BY THE REGISTER OF DEEDS AND RETURNED TO THE <br />DEPARTMENT OF REVENUE. <br />GOLDENROD: TO BE KEPT BY THE REGISTER OF DEEDS. <br />BILLING IS TO BE ONCE PER MONTH AND THERE WILL BE NO PRE - PAYMENT OF FEES. <br />THANK YOU FOR YOUR COOPERATION. <br />C <br />