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r icesi Lite. Sr... Service <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2110001243-0 Pages: 1 <br />Debtor Name: KELLIE M CHACON <br />Filing Date and Time 10/29/2021 11:15 AM <br />Notice of State Tax Lien <br />262109197 <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 Tien 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 NOTWRITE IN THIS SPACE <br />Nebraska ID Number <br />46594469 <br />Federal ID Number <br />Lien Serial Number <br />12183252 <br />Lien Filed Wrlhi <br />Social Security Number <br />XXX -XX -2140 <br />Spouses Social Security Number <br />1:1 Register cl Deeds • county Clerk <br />Date of Lien <br />October 21, 2021 <br />Lien Type: <br />® Original 0Continuation [Corrected <br />County <br />HALL <br />Business Name and Location Address <br />assayer Na <br />KELLIE M CHACON <br />1114 W LOUISE ST APT 2 <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 />$295.51 <br />$16.15 <br />$46.57 <br />358.23 <br />Individual <br />2018 <br />11/23/2019 <br />$598.00 <br />$29.90 <br />$65.73 <br />693.63 <br />Total <br />$1,051.86 <br />1 certify that the Nebraska Department of Revenue has complied with the laws of the State of Nebraska in determining the amount shown 10 be due, <br />and that the taxpayer has tailed to pay the amount due after demand. This Nonce of State Tax Lien is an elective Fen and serves to continue the priority of <br />the States interest kr Ore affected properly of Lite taxpayer. <br />signSrld a <br />here r etPreparers 3i <br />Autnorized Signature <br />Revenue Agent <br />Title <br />Revenue Supervisor <br />10/21/2021 (308)632-1210 <br />Date Phone Number <br />10/21/2021 <br />Title Date <br />4-494.1905 Rd. 8-2010 Super ales 4949 rata Ren 82013 <br />