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NEB AS -KA <br />.sad I..de,. v•rcat Service. <br />xcw4,r4r0o. nmuw <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2003000504-2 Pages: 1 <br />Debtor Name: JAMIE MARTIN <br />Filing Date and Time: 03/11/2020 11:26 AM <br />Notice of State Tax Lien <br />202001599 <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 1O 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 ID Number <br />9004467 <br />edeurt 2 Number <br />Lien Scoot Num <br />11943517 <br />Li cn tiled With; <br />ter n+Deeds fl County Clerk <br />Social Security Number <br />XXX -XX -2074 <br />Spouses Social Security Number <br />Date of Lien <br />November 20, 2019 <br />Lien <br />Original <br />Continuation ❑Corrected <br />County <br />I IA LL <br />Business Name and Location Addre <br />Taxpayer Name and Mailing Address <br />JAMIE MARTIN <br />2309 N WEBI3 ROAD <br />GRAND ISLAND NE 68803 <br />Tax Program Tar Period <br />Date of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costs <br />Total Due <br />Sales 101/01./2019 - 01/31/2019 <br />06'03/2019 t .00 <br />24.78 <br />.17 <br />.00 <br />24.95 <br />Sales 02/01/2019-02/28i2019 <br />06;03/2019 <br />.00 <br />25.00 <br />.40 <br />.00 <br />25.40 <br />Sales 03/01?2019 - 03/31,2019 <br />06/03/2019 <br />.00 <br />25.00 <br />.19 <br />.00 <br />25.19 <br />Sales 04/01'2019-07/31/2019 <br />1113./2019 <br />320.00 <br />132.00 <br />6.05 <br />.00 <br />458.05 <br />Total <br />533.59 <br />I certify that tine Nebraska Department of Revenue has complied ant the laws of the State of Nebraska in determining the amountshown to i ele :toe, <br />and that the taxpayer has tailed to pay the amount due after demand. This Notice el Slate Tax Lien is an effective ter ant staves to 00rihnue toe priority of <br />the State's n the aterlSd jlrrperly of the taxpayer. <br />sign <br />here r Preparers Si <br />Authorized S gnat <br />"menti Revenue Senior Agent <br />JD/?+tltm. <br />Title <br />Revenue Senior Agent <br />Titin <br />1111312019 402-471-5709 <br />Dale <br />PhoneNumber <br />Dale <br />4-494-t94 tSyo 1)-20', 8 3uxrs ,dss 4-9e 9.1974 Rev, 0-2aT3 <br />