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Good Ler. Cleat Servire, <br />ora++«erc or 4wsruxt <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2106001163-2 <br />Debtor Name JUAN MARTINEZ ZARATE <br />Filing Date and Time. 06/25/2021 10:10 AM <br />Pages: 1 <br />Notice of State Tax Lien <br />202105.398 <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 lien will expire and <br />become unenforceable 10 years after the date of recording it 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 />90711882 <br />Federal D Number <br />Len Serial Number <br />12175329 <br />Date of Lien <br />June 22,2021 <br />Lien Filed With: <br />Register of Deeds El County Clerk <br />Social Security Number <br />XXX -XX -0204 <br />I <br />Spouses Social Security Number <br />L=en Type: <br />®Original ElContinuation El Cor <br />County <br />Corrected <br />Business Name and Location Address <br />HALL <br />Taxpayer Name and Mailing Address <br />JUAN MARTINEZ ZARATE <br />1108 AVE A <br />DODGE CITY KS KS 67801 <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 />08/07/2020 <br />$96.00 <br />$285.25 <br />$134.09 <br />515.34 <br />Individual <br />2018 <br />05/14/2019 <br />$.00 <br />$9.45 <br />$.47 <br />9.92 <br />Individual <br />2019 <br />08/07/2020 <br />$441.00 <br />$22.05 <br />$16.48 <br />479.53 <br />Total <br />$1,004.79 <br />1 eerlrly 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 faded 10 pay the amount due after demand. This Notice of State Tax Liar Is an efactive ken and serves to contuse the priority of <br />Nie Stale's interest in the affected property of the taxpayer. <br />sign Revenue Senior Agent 06/22/2021 (402)471-4339 <br />here i► Repairer's Stratuie > ✓' . Title Date Phone Number <br />'z=«e Revenue Supervisor 06/22/2021 <br />rjpft+orized Signatut6 Title Date <br />4-194.1974 S®r. 8-2018 ,..p."0184101 4-A49.1974 ncv. 84013 <br />