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' YE R D-. <br />Wort vreeT ce <br />00,10,01•110, 0/ IINVY•NVe <br />20210526 <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2109001327-5 Pages: 1 <br />Debtor Name: ANDREW WERTZ <br />Filing Date and Time: 09/28/2021 09:43 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 />41165683 <br />Federal ID Number <br />Lien Serial Number <br />12181304 <br />Len Filed With: <br />® Register of Deeds Counly Cterk <br />Social Security Number <br />XXX -XX -3365 <br />Spouse a Social Security Number <br />Date of Lien <br />September 22, 2021 <br />Llan Type: <br />® Original ❑ Continuation <br />10/30/2019 <br />County <br />HALL <br />• Corrected <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />ANDREW WERTZ <br />1041 S LOCUST <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 />10/30/2019 <br />$1,398.00 <br />$69.90 <br />5150.33 <br />1.618.23 <br />Total <br />$1.618.23 <br />sign <br />here <br />1 earthy t <br />and that <br />the Sta <br />Revenue has complied with the laws of the Stale of Nebraska in detsrmireng the amount shown 10 be due. <br />ount due after demand. This Notice of State Tax Lien is an effective lien and serves to continue the priority of <br />ty of the taxpayer. <br />Preparers Signe <br />Autrlerix :.nature <br />Revenue Agent 09/22/2021 (308)632-1210 <br />Title Dao Phone Number <br />Revenue Supervisor 09/22/2021 <br />Tine Data <br />«94.t974 Pow 82018 Summon 4.9x9.'974 Ran 8.2013 <br />