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C;ocvY 1. te. crewt Sa.v ce. <br />...Wm., a «.r.w <br />202005410 <br />NI: Sec of State - Robert 43. Evnen <br />Filing Document #: 2007001125-2 Pages: 1 <br />Debtor Name: JESSE W FRANCIS <br />Filing Date and Time: 07/28/2020 08:48 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 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 00 NOT WRITE IN THIS SPACE <br />PLEASE RETURN TO: <br />NEBRASKA DEPT OF REVENUE <br />PO BOX 94609 <br />LINCOLN NE 68509-4609 <br />Nebraska ID Number <br />26765713 <br />Federal ID Number <br />Lien Serial Number <br />12058833 <br />Lien Filed With. <br />Social Security Number <br />XXX -XX -1704 <br />Spouses Social Securtty Number <br />® Register of Deeds ■ County Clerk <br />Date of Lien <br />July 24, 2020 <br />Lien Type: <br />$296.00 <br />$14.80 <br />County <br />HALL <br />® Original ■ Continuation <br />■ Corrected <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />JESSE W FRANCIS <br />2720 W CHARLES 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 />Individual <br />2015 <br />12/24/2018 <br />$296.00 <br />$14.80 <br />$47.24 <br />358.04 <br />Total <br />$358.04 <br />sign <br />here <br />I certify that the Nebraska Depar . M o1 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 failed to y bre amo due after demand. This Notice of State Tax lien is an effective ken and serves b continue the priority of <br />the State's interest in the affected ty of <. taxpayer, <br />AF if Revenue Agent <br />if. a! 1 <br />Authorized Signatu�� , Title Date <br />a-494.1074 Pee. 62018 SUMMON 4.949•'974 Pea. 62013 <br />Title <br />Revenue Supervisor <br />07/24/2020 (308)632-1208 <br />Dab Phone Number <br />07/24/2020 <br />