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NtEB A&K' <br />(,ot1U _:te. 3'est }ff!'tiC:9. <br />0.407,141.7 1.1*PFUR <br />202004917 <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2007000583-5 <br />Debtor Name: ENRIQUE MATA-SAMANO <br />Filing Date and Time: 07/14/2020 10:23 AM <br />Pages: 1 <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 />Nobraslta ID Number <br />12994928 <br />Federal D Number <br />Len Serial Number <br />12057620 <br />Llen Fled Nfiih: <br />(] Register al Deeds ❑County Clerk <br />Social SeCurgy Number <br />XXX -XX -4459 <br />Spouses Social Seouaity Number <br />XXX -XX -6655 <br />Date of Lien <br />July 6, 2020 <br />Lien Type: <br />® Original ❑C«eauation <br />I1/01/2017 <br />County <br />HALL <br />I. Corrected <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />ENRIQUE MATA-SAMANO & FRANCIS M MATA <br />1624 W 3RD 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 />01/01/2011 -09/30/2017 <br />I1/01/2017 <br />7,989.74 <br />1,346.46 <br />3,051.17 <br />,00 <br />12,387.37 <br />Total <br />12,387.37 <br />I certify that the Nebraska Department of Rename has complied with the laws o11he State of Nebraska In determining the amount shown to be due, <br />and Mal the taxpayer fes tailed le pay the amount due alter demand. This Notice 04 Stale Tart Len is an effective Sen and serves to continue the priority of <br />the Suite's interest in ISa affected property of the taxpayer. <br />sign,f. Revenue Senior Agent 07/06/2020 402-471-5727 <br />hereProparer'sS/!A Tale Date Phone Number <br />7-7,�� j n' Revenue Senior Agent 07/06/2020 <br />Authorized Signature <br />Tide Date <br />445n•1974 Rev..1}2018 Supersedes 4.949.1874 Per. 8.2013 <br />