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NEBRASKA <br />rood LAe. Great Sewce. <br />202006777 <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2009000379-2 Pages: 1 <br />Debtor Name: GOSAN, INC <br />Filing Date and Time: 09/10/2020 09:54 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 Ilen 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 INTHIS SPACE <br />Nebraska 10 Number <br />9076352 <br />Federal ID Number <br />470838370 <br />Lien Serial Number <br />12061080 <br />Lien Filed With: <br />® Register of Deeds ❑ County Clerk <br />Social Security Number <br />Spouse's Social Security Number <br />Date of Lien <br />September3, 2020 <br />Lien Type: <br />❑Corrected <br />County <br />HALL <br />M c.ig.il ❑Continuation <br />usiness Name and Location Address <br />Taxpayer Name and Mailing Address <br />GOSAN, INC <br />D/B/A GOSAN SUPER BOWL <br />1010 E BISMARK <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 />Sales <br />10/01/2018- 10/31/2018 <br />01/02/2019 <br />.00 <br />.00 <br />6.27 <br />.00 <br />6.27 <br />Sales <br />12/01/2018- 12/31/2018 <br />02/01/2019 <br />.00 <br />.00 <br />1.58 <br />.00 <br />1.58 <br />Sales <br />04/01/2019 - 04/30/2019 <br />07/01/2019 <br />.00 <br />.00 <br />4.84 <br />.00 <br />4.84 <br />Sales <br />05;01/2019 - 05/3112019 <br />08/23/2019 <br />.00 <br />.00 <br />45.84 <br />20.00 <br />65.84 <br />Sales <br />06/01/2019 - 06/30/2019 <br />09/03/2019 <br />.00 <br />.00 <br />20.86 <br />.00 <br />20.86 <br />Saks <br />08./01/2019-08/31:2019 <br />11/01/2019 <br />.00 <br />71.46 <br />4.85 <br />.00 <br />76.31 <br />Sales <br />09/01/2019 - 12/31/2019 <br />02/03/2020 <br />11,094.39 <br />850.74 <br />409.32 <br />.00 <br />12,354.45 <br />Sales <br />01/0112020-03/31/2020 <br />07/01/2020 <br />8,329.16 <br />832.92 <br />198.85 <br />.00 <br />9,360.93 <br />Withholding <br />04/01/2019 - 06/30/2019 <br />09/26/2019 <br />.00 <br />.00 <br />6.29 <br />.00 <br />6.29 <br />Withholding <br />07/01/2019- 12/31/2019 <br />02/10/2020 <br />1,091.89 <br />296.95 <br />52.13 <br />.00 <br />1,440.97 <br />Total <br />23,338.34 <br />1 certify that the Nebraska Department of Revenue has complied With the laws of the State of Nebraska in determining the amount shown to be due, <br />and that the taxpayer Fres failed to pay the amount due after demand. This Notice of State Tax Lien is an effective hen and serves to continue ON prlonly of <br />the State's Interest in the seeded property of Me taxpayer. <br />sign <br />here Proparer alar <br />Authorized Signature <br />Revenue Senior Agent <br />rue <br />Revenue Senior Agent <br />09/03/2020 402-471-5727 <br />Date <br />Tido <br />Phone Number <br />09/03/2020 <br />Date <br />4.4941074 Re, 62018 Suoarsedes x.ax9-197r Rer. 6.201 <br />