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NFoo, <br />(iaao ,.ate. Greg: Sery-ce. <br />202003818 <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2006000477-6 Pages: 1 <br />Debtor Name: TENLEY JANSEN <br />Filing Date and Time: 06/09/2020 09:10 AM <br />Notice of State Tax Lien <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 />PLEASE DO NOT WRITE IN THIS SPACE <br />Nebraska ID Number <br />12982024 <br />Federal ID Number <br />811574740 <br />Lien Serial Number <br />12054574 <br />Lien riled With' <br />Social Security Number <br />XXX -XX -4308 <br />Spouse's Social Security Number <br />fM-' Register of Deeds • County Clerk <br />Date of Lien <br />May 21, 2020 <br />Lien Type: <br />962.62 <br />333.34 <br />County <br />HALL <br />1 Original • Continuation <br />• Corrected <br />usiness Name and Location Address <br />Taxpayer Name and Mailing Address <br />TENLEY JANSEN <br />2219 14111 AVE <br />CENTRAL CITY NE 68826 <br />Tax Program <br />Tax Period <br />Date of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costs <br />Total Due <br />Withholding <br />07/01(2018 - 09/30'2018 <br />051052019 <br />962.62 <br />333.34 <br />76.99 <br />.00 <br />1,372.95 <br />Withholding • <br />10101//2018- 12'31/2018 <br />0510512019 <br />1,180.00 <br />236.00 <br />76.94 <br />.00 <br />1,492.94 <br />Withholding <br />01/01/2019 - 03/31!2019 <br />11:212019 <br />490.00 <br />171.50 <br />25.99 <br />.00 <br />687.49 <br />Withholding <br />04101,'2019 - 06/30/2019 <br />11/23/2019 <br />490.00 <br />98.00 <br />19.81 <br />.00 <br />607.81 <br />Total <br />4,161.19 <br />1 certify that the Nebraska Department or Revenue has complied with the laws of the State of Nebraska in determining the amount shown to be due. <br />and that the taxpayer has faded to pay the amount due after demand- This Notice of State Tax Lien is an effective lien and serves to continue the priority of <br />the Stales interest in the affected property of the taxpayer. <br />signs <br />C� ��✓lamdl t 402-471-5709 <br />�_t.,� <br />here r Prepares Signatures Tele i-, Date Phone Number <br />Authorized Signature / Title <br />Date <br />4-494-1974 ne, &tote Si,pvrsedns 4.949.19/4 1109. 8-2!:15 <br />