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.,.tow, fe (.ie Set t - re. <br />A00006383 <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2008001032-2 Pages: 1 <br />Debtor Name: SERGIO DOMINGUEZ <br />Filing Date and Time: 08/27/2020 11:08 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 />PLEASE RETURN TO: <br />NEBRASKA DEPT OF REVENUE <br />PO BOX 94609 <br />LINCOLN NE 68509-4609 <br />Nebraska ID Number <br />94789541 <br />Federal ID Number <br />Lien Serial Number <br />12060365 <br />Lien FNad With: <br />Social Security Number <br />XXX -XX -5880 <br />Spouse's Social Security Number <br />XXX -XX -1990 <br />i7 Register of Deeds ❑ County Clerk <br />Date of Lien <br />August 24, 2020 <br />Lien Type: <br />$354.00 <br />$17.70 <br />County <br />HALL <br />® Original In Continuation <br />■ Corrected <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />SERGIO DOMINGUEZ <br />CLAUDIA J GONZALEZ ORTIZ <br />2323 BELLWOOD DR APT 75 <br />GRAND ISLAND NE 68801 <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 />2016 <br />01/12/2020 <br />$354.00 <br />$17.70 <br />$47.38 <br />419.08 <br />Total <br />$419.08 <br />sign <br />here <br />I candy that the Nebraska Department of Revenue has complied wan 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 alter demand. This Notice of State Tax Lien is an effective lien and serves to continue the priority of <br />the States interest in the alleged property ol 11w taxpayer. <br />Revenue Agent 08/24/2020 (308)632-1203 <br />S. • Title Date Phone Number <br />/J Revenue Supervisor 08/24/2020 <br />�nWinuu• Si. urs Title Dale <br />4-494-t974 tlev. 9.2018 Suorsedes 4a4a-tan Rev 8-20,3 <br />