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1 <br />Gocd Lite. Great Sc•vice, <br />w.wr.wn r 11111.xwa <br />20210307/ <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2104000819-9 Pages: 1 <br />Debtor Name: JOSE WILBER GOMEZ <br />Filing Date and Time: 04/15/2021 10:46 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 Tien 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 Tien 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 Tien or continuation statement. <br />PLEASE 00 NOT WRITE IN THIS SPACE <br />Nebraska ID Number <br />8134146 <br />Federal 0 Number <br />Lien Serial Number <br />12169346 <br />Lien Filed With: <br />&I Reglstr °I1)°°°' 50 County Ckerk <br />S0041 Security Number <br />XXX -XX -3197 <br />Spouse's Social Security Number <br />Date of Lien <br />February 26, 2021 <br />Lien Type: <br />J Original ❑contuuation 0Corrected <br />County <br />HALL <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />JOSE WILBER GOMEZ <br />WILBERS AUTO REPAIR <br />523 N PINE ST <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 />01/01/2014 - 08/31/2017 <br />02/12/2020 <br />10,201.92 <br />1,140.41 <br />2,056.15 <br />.00 <br />13,398.48 <br />Sales <br />02/01/2020 - 02/29/2020 <br />05/01/2020 <br />.00 <br />25.00 <br />.30 <br />.00 <br />25.30 <br />Sales <br />04/01/2020 - 04130/2020 <br />08/03/2020 <br />.00 <br />25.00 <br />.87 <br />.00 <br />25.87 <br />Sales <br />05/01 /2020 - 05/31/2020 <br />08/03/2020 <br />.00 <br />25.00 <br />.40 <br />.00 <br />25.40 <br />Total <br />13,475.05 <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 has tailed b pay the amount due after demand. This Notice of State Tax lien is en effective ken and serves to continue trte priority of <br />the States interest in the affected property of the taxpayer. <br />sign, X W(L 1/4 ; i\tj <br />here P Preparers Signat <br />itri v7(� <br />Authorized S tune <br />Revenue Agent <br />Title <br />Revenue Senior Agent <br />02/19/2021 402-471-5723 <br />Date <br />Title <br />Prone Number <br />04/06/2021 <br />Date <br />4d94-1974 Pao &.20t8 Suoaneoes 4.949.!974 Ilex 61013 <br />