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N EB. K.A- <br />_,u:-c;d <br />20210485r <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2106000362-4 Pages: 1 <br />Debtor Name: TIMOTHY S SMITH <br />Filing Date and Time: 06/08/2021 09:45 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 />Nebraska ID Number <br />43136214 <br />Federal ID Number <br />Lion Serial Number <br />12174474 <br />Lien Fled With: <br />Social Security Number <br />XXX -XX -1057 <br />Spouses Social Security Number <br />® Register of Deeds • County Clerk <br />Date of tion <br />June 02, 2021 <br />Lien Type: <br />®aiginai ❑Continuation 1:3 Corrected <br />County <br />HALL <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />TIMOTHY S SMITH <br />19617 BLAINE CIR <br />OMAHA NE 68135 <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 />2018 <br />09/15/2020 <br />$4,437.00 <br />$1,210.25 <br />$436.28 <br />6.083.53 <br />Individual <br />2019 <br />11/20/2020 <br />$3,851.00 <br />$307.55 <br />$137.58 <br />4,296.13 <br />Total <br />$10,379.66 <br />I certify that the Nebraska Department of Revenue has complied with the laws of the State of Nebraska in determining the amount shown lobe due. <br />and that the taxpayer has failed to pay the amount due after demand. This Notice of State Tax Lien is an effective lien and serves to continue the priority Of <br />the State's interest In the sheeted property of the taxpayer. <br />sign 5'. z,ta yS/ <br />here Ropare'sSire <br />�� f, <br />Authorized Signature <br />Revenue Agent 06/02/2021 (308)632-1208 <br />Tate Date Phone Number <br />Revenue Supervisor 06/02/2021 <br />Title Date <br />4 -44s -197a rev, 8-2019 Supersecw 4.949.1974 Wo. 62015 <br />