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NEEB+E4. <br />3 0o L fe. <br />202108039 <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2109000955-5 Pages: 1 <br />Debtor Name: MONGOLIAN GRILL RESTAURANT <br />Filing Date and Time: 09/21/2021 09:38 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 Iien.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 />13458310 <br />Federal D Number <br />611946587 <br />Lien Serial Number <br />12104055 <br />Lier Feed With. <br />® Resister of Deeds ['County Clem <br />Sooal Security Number <br />Spouses Social Security Number <br />Date of liar <br />August 31, 2021 <br />Lier Type: <br />0 Original ❑ Continuation <br />09/01/2020 <br />Courcy <br />HALL <br />• Corrected <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />MONGOLIAN GRILL RESTAURANT <br />1816 WEBB RD <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 />Saks <br />07/01/2020 - 07/31/2020 <br />09/01/2020 <br />.00 <br />139.90 <br />.38 <br />.00 <br />140.28 <br />Saks <br />08;01/2020 - 08/31/2020 <br />09/28/2020 <br />.00 <br />153.06 <br />9.85 <br />20.00 <br />182.91 <br />Sales <br />09101/2020 - 09/30/2020 <br />11/02/2020 <br />1,764.51 <br />150.68 <br />63.22 <br />20.00 <br />1,998.41 <br />Saks <br />10/01/2020 - 10/31/2020 <br />01/0412021 <br />.00 <br />144.44 <br />1.98 <br />.00 <br />146.42 <br />Saks <br />11/01/2020- 11/30/2020 <br />01/11/2021 <br />1,272.88 <br />127.29 <br />26.81 <br />20.00 <br />1,446.98 <br />Sales <br />1 2/01/2020 - 12/31/2020 <br />02/09/2021 <br />1.341.78 <br />134.18 <br />24.60 <br />20.00 <br />1,520.56 <br />Sales <br />01/01/2021 -01/31/2021 <br />04/01/2021 <br />.00 <br />160.33 <br />4.20 <br />.00 <br />164.53 <br />Sales <br />02/01/2021 - 02/28/2021 <br />04/01/2021 <br />.00 <br />136.50 <br />.00 <br />.00 <br />136.50 <br />Sales <br />03/01/2021 -04/30/2021 <br />06/01/2021 <br />1,829.23 <br />168.15 <br />20.27 <br />20.00 <br />2,037.65 <br />Saks <br />05;01/2021 - 05/31/2021 <br />08/02/2021 <br />1.989.52 <br />198.95 <br />11.78 <br />.00 <br />2,200.25 <br />Sales <br />06/01;2021 -06/30/2021 <br />08/02/2021 <br />1,771.53 <br />177.15 <br />6.12 <br />.00 <br />1,954.80 <br />Total <br />11.929.29 <br />sign <br />here <br />I Ceeh y thal the Nebraska Department of Revenue has compked with me laws of the State of Nobraska in determinmq the amount shown to be sue. <br />and t'W I the taxpayer ties failed to pay the amount due atter demand. This Notice of State Tax Lien is an eflecave hen and serves to continue the pnoety of <br />the States mbres1 on the affected property of the taxpayer. <br />Signature <br />Authorized <br />Revenue Agent <br />Title <br />Revenue Senior Agent <br />Title <br />08/24/2021 402-471-5870 <br />Phone Number <br />Q/7/zo2� <br />Date <br />4-494-•974 f .62018 Swanenus 0.9m9••9/0 Po. 62013 <br />