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NJKA- <br />:5_ad le. Great Ser,ce. <br />ZU2UU2U33 <br />NE See of State - Robert B. Evnen <br />Filing Document #: 2004000118-8 Pages: 1 <br />Debtor Name: VITAL SIGNS INC <br />Filing Date and Time: 04/02/2020 09:18 AM <br />Notice of State Tax Lien <br />This Notice of State Tax Lien is issued by the Nebraska <br />Department of Revenue tor 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 Iien.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 />PLEASE DO NOT WRITE IN THIS SPACE <br />Nebraska 0 Numbc <br />8115109 <br />Federal ID Number <br />470813036 <br />Lien SCrial Num <br />12050705 <br />.len Filed With <br />® Register of Deeds El County Clerk <br />Social Security Number <br />Spouse's Social Secunty Number <br />Date of Lien <br />March 19, 2020 <br />Lien Type: <br />® Ori;inal Continuation Corrected <br />County <br />HALL <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />VITAL SIGNS INC <br />2218 WEST 2ND ST <br />GRAND ISLAND NE 68803 <br />Tax Program <br />Tax Period <br />Date of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costs <br />Total Due <br />Sales <br />07/01/2017 - 09/30/2017 <br />10/28/2019 <br />136.74 <br />71.60 <br />36.75 <br />.00 <br />245.09 <br />Sales <br />04/012018 - 06/30/2018 <br />10/28/2019 <br />405.00 <br />81.00 <br />30.08 <br />.00 <br />516.08 <br />Sales <br />07/01/2018 - 09/30/2018 <br />10/28/2019 <br />405.00 <br />81.00 <br />27.02 <br />.00 <br />513.02 <br />Sales <br />10/01/2018 - 12/31/2018 <br />10/28/2019 <br />405.00 <br />81.00 <br />23.52 <br />.00 <br />509.52 <br />Withholding <br />10/01/2016 - 06/30/2017 <br />11/20/2017 <br />.00 <br />75.00 <br />.00 <br />.00 <br />75.00 <br />Withholding <br />07/01/2017 - 06/30/2019 <br />10/28/2019 <br />700.00 <br />345.00 <br />44.90 <br />.00 <br />1,089.90 <br />Withholding <br />01/01/2018 - 03/31(2018 <br />10/28/2019 <br />100.00 <br />35.00 <br />8.10 <br />.00 <br />143.10 <br />Withholding <br />04/01/2018 - 06/302018 <br />101282019 <br />100.00 <br />35.00 <br />7.34 <br />.00 <br />142.34 <br />Total <br />3,234.05 <br />I certrly that the Nebraska Department of Revenue has comphed with the laws of the State of Nebraska in determining the amount shown to be due, <br />and that the taxpayer has tailed to pay the amount due after demand. This Notice of Slate Tax Lien is an effective lien and serves to Continue the priority ol <br />the State' syll <br />sign 'crest in the affected property of the taxpayer. <br />j1)Q.O <br />here Preparer's Sig <br />• 4r <br />Authorized Sgnalur <br />Revenue Senior Aient <br />03/12/2020 402-471-5709 <br />Title <br />Revenue Senior Agent <br />Dale Phone Numb `r <br />3J 7 j�?crx <br />Title <br />Date <br />4-494-!974 Ren. 8.20+11 Supersedes 4.949.1914 Rev. 8-2:13 <br />