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N <br />G000 Life. G'ea: Service. <br />NMIMM, M 4.11.11 <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2110000755-3 Pages: 1 <br />Debtor Name: VICTOR H CHAVEZ <br />Filing Date and Time: 10/20/2021 10:47 AM <br />Notice of State Tax Lien <br />202198899 <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 INTHIS SPACE <br />Nebraska ID Number <br />11291885 <br />rederal ID Number <br />455096914 <br />Lien Serial Number <br />12104708 <br />Lien Filed Wilk. <br />Social Security Number <br />XXX -XX -5842 <br />Spouse's Social Security Number <br />r Register of Deeds • County Cleric <br />Date of Lien <br />October 15, 2021 <br />Lien Type: <br />.00 <br />28.40 <br />County <br />HALL <br />® original • continuation <br />al Corrected <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />VICTOR H CHAVEZ <br />AMERICA SEAMLESS GUTTERS <br />418 E 13TH ST <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 />Withholding <br />10/01/2018- 12/31/2018 <br />05/10/2019 <br />.00 <br />28.40 <br />1.84 <br />.00 <br />30.24 <br />Withholding <br />04/01/2019- 12/31/2019 <br />05/31/2021 <br />645.00 <br />225.75 <br />52.50 <br />.00 <br />923.25 <br />Withholding <br />01/01/2020 - 03/31/2020 <br />05/31/2021 <br />215.00 <br />75.25 <br />9.44 <br />.00 <br />299.69 <br />Withholding <br />10/01/2020- 12/31/2020 <br />05/31/2021 <br />645.00 <br />204.25 <br />20.53 <br />.00 <br />869.78 <br />Total <br />2,122.96 <br />I certify that the Nebraska Department of Revenue has complied with the laws of the Stale of Nebraska in determining the amount shown to be due <br />and that the taxpayer has laded to pay the amount due after demand. This Notice of Slate Tax Lien is an effective lien and serves to continue the priority of <br />the States interest in the affected properly ot the taxpayer. <br />sign, L4/e„si <br />here r Preparer's Si I C \� <br />Authorized Signa ure <br />Revenue Agent 10/15/2021 402-471-5870 <br />Title Date Phone Number <br />Revenue Supervisor /C—j,6"-...1,, a./ <br />Title Date <br />4-494-1974 Rev. 9.9015 Supesedes 49494974 lien e.2013 <br />