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N EBA.,+4A- <br />3ocd Lite. Greet Sere _e <br />00.0.11•0•10 Of 0/000•1011 <br />37r <br />NE Sec of State - Robert H. Evnen <br />Filing Document #: 2105001047-6 <br />Debtor Name: MARILYN R HAVERLUCK <br />Filing Date and Time: 05/24/2021 09:22 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 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 Ilen.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 Tien or continuation statement. <br />PLEASE DO NOT WRITE IN THIS SPACE <br />Nebraska ID Number <br />39016986 <br />Federal ID Number <br />Lien Serial Number <br />12173892 <br />Lien Fieri with: <br />Social Security Number <br />XXX -XX -4184 <br />Spouse's Social Security Number <br />pi Rglater of Deeds ❑ county clerk <br />Dale of Lien <br />May 18, 2021 <br />Len Type. <br />❑corrected <br />County <br />HALL <br />1 Original ■ Continuation <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />MARILYN R I-IAVERLUCK <br />222 W 6TH 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 />Individual <br />2017 <br />05/16/2020 <br />$144.02 <br />$20.15 <br />$51.32 <br />215.49 <br />Total <br />$215.49 <br />I certify that the Nebraska Department of Revenue has complied with the laws oI the State of Nebraska in determining the amount shown to be due. <br />and that the taxpayer has failed to pay the amount due atter demand. This Notice of State Tax Lien Is an elective gen and serves o continuo the priority of <br />the States 000,0st m the affected property of the taxpayer. <br />sign <br />here Raparers lure <br />!4,1001,0 <br />a/1. <br />Revenue Agent 05/18/2021 (402)471-5833 <br />ntte Date Phone Number <br />Revenue Supervisor 05/18/2021 <br />Title Date <br />4404-1974 Rev. a20re S,pereedos 4-949.1974 net, 6.2013 <br />