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o`s <br />:.ted l,ff?. <br />NE Sec of State - Robert B. Evnen <br />Filing Document 4: 2109001047-2 <br />Debtor Name: ISRAEL MENDEZ <br />Filing Date and Time: 09/22/2021 10:30 AM <br />Pages: 1 <br />Notice of State Tax Lien <br />2®2108080 <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 />91581761 <br />Federal ID Nurnbet <br />Lien Serial Number <br />12180863 <br />Len Filed With: <br />j Register of Deeds fl County Clerk <br />Social Security Number <br />XXX -XX -4388 <br />Spouse's Social Security Number <br />XXX -XX -1060 <br />Date of Lien <br />September 16, 2021 <br />Len Type: <br />E Corrected <br />County <br />HALL <br />K1 Original ■ Continuation <br />Business Name end Location Address <br />Taxpayer Name and Mailing Address <br />ISRAEL MENDEZ <br />JENNIFER K MENDEZ <br />512 EAST SUNSET AVENUE <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 />2018 <br />11/08/2019 <br />$203.00 <br />$32.65 <br />$57.33 <br />292.98 <br />Individual <br />2019 <br />09/01/2020 <br />$828.00 <br />$16.00 <br />$36.79 <br />880.79 <br />Total <br />$1,173.77 <br />sign <br />here <br />I certify 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 failed to pay the amount due after demand. This Notice of State lax Lien is an effective Hen and serves to continue the priority of <br />the States interest in the effected property of the taxpayer. <br />8rii?"et Martin, <br />/wtvsrized Signature <br />Revenue Agent 09/16/2021 (308)632-1210 <br />Title Date Phone Number <br />Revenue Supervisor 09/16/2021 <br />Tele <br />Date <br />4-04497 hex 6-20+e Supe cedes a-948.1971 Rev. a -20r 3 <br />