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C:00 Lila. Grew: Sr;evce. <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2107001967-9 Pages: 1 <br />Debtor Name: HARVEY EVANS <br />Filing Date and Time: 07/30/2021 10:59 AM <br />Notice of State Tax Lien <br />2.02106515 <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 lien will expire and <br />become unenforceable 10 years after the date of recording 11 no <br />continuation statement is recorded on or prior to the expiration of <br />the previous lien or continuation statement. <br />PLEASE 00 NOT WRITE IN THIS SPACE <br />Nebraska ID Number <br />39756572 <br />Federal ID Number <br />Len Serial Number <br />12177392 <br />Lien Filed With: <br />® Register of Deeds 0 County Clerk <br />Social Security Number <br />XXX -XX -0268 <br />Spouse's Social Security Number <br />Date of Lien <br />July 28, 2021 <br />Lien Type: <br />11/03/2020 <br />$3,724.00 <br />County <br />HALL <br />FA Original ■ Continuation <br />■ Corrected <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />HARVEY EVANS <br />PO BOX 1285 <br />GRAND ISLAND NE 68802 <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 />2019 <br />11/03/2020 <br />$3,724.00 <br />$210.20 <br />$150.18 <br />4,084.38 <br />Total <br />$4,084.38 <br />I certify that the Nebraska Department of Revenue hes convoked with the laws of tie State of Nebraska In determining the amount shown to be due. <br />and that the taxpayer has tailed to pay the amount due after demand. This Notice of Slate Tax Lien is an effective lien end serves to contrive 111e priority o1 <br />the State's interest in the effected property of the taxpayer. <br />signRevenue Agent 07/28/2021 (402)471-0987 <br />here r Preparer's Signature /� Title Date Phone Number <br />)t- Revenue Supervisor 07/28/2021 <br />, utnurized Signature Tide Date <br />4-494-1974 Rev. 6-2018 Sope t.,des 4.040-1074 Fiero, 6-2013 <br />