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fB <br />iobcl Lite. <i,e,,t Sere en. <br />e4uMeb,T srserrerr <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2110000458-3 Pages: 1 <br />Debtor Name: JOSE I RUIZ TAPIA <br />Filing Date and Time 10/14/2021 09:24 AM <br />Notice of State Tax Lien <br />2.0 21087 30 <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 costa, <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 />42649919 <br />Federal ID Number <br />Lien Serial Number <br />12182097 <br />Lien Filed With: <br />Social Security Number <br />XXX -XX -0056 <br />Spouse's Social Security Number <br />® Reg tor of Deers • County Clerk <br />Date of Lien <br />October 05, 2021 <br />Lien Typo: <br />® Original ❑ Continuation <br />$398.00 <br />County <br />HALL <br />• Corrected <br />usiness Name and Location Address <br />Taxpayer Name and Mailing Address <br />JOSE I RUIZ TAPIA <br />1408 SOUTH EDDY <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 />2017 <br />11/23/2019 <br />$398.00 <br />$21.75 <br />$60.63 <br />480.38 <br />Individual <br />2018 <br />11/23/2019 <br />$1,544.00 <br />$77.20 <br />$167.69 <br />1,788.89 <br />Total <br />$2,269.27 <br />I certify that the Nebraska Department of Revenue has complied with Um taws of to State of Nebraska in determining the amount shown to be due. <br />and mal the taxpayer has failed to pay the amount due after demand. This Notice of State Tax Lien Is an effective ken and serves to continue the prwrty of <br />the State's interact In the affected property dl the taxpayer. <br />sign <br />here r Preparer's Signature <br />frithorized Signa)ro <br />Revenue Agent 10/05/2021 (402)471-6043 <br />Tete Date Phone Number <br />Revenue Supervisor 10/05/2021 <br />Tine Date <br />4404.1874 Iier.8-20.3 Supoisedee 4448.1974 nen. 92013 <br />