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Nf PAS4 <br />.,.n;d Lee Great S.ere,e <br />POH.41,1410 Of <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2211000145-0 Pages: 1 <br />Debtor Name: TIFFANY PENDERGRAFT <br />Filing Date and Time: 11/07/2022 08:37 AM <br />Notice of State Tax Lien <br />202207872 <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 area 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 Hen 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 />114511097 <br />Federal ID Number <br />461817825 <br />Lan Serial Nurrber <br />12212:189 <br />Lien Filed WO: <br />Social Security Number <br />](-x_)()(_1795 <br />Spouse's Sochi Security N.nnber <br />i7 tiel�lstoroIDeed luCounty Ceti <br />Date of Lien _ <br />October 26, 2022 <br />Lien Type: <br />® ofiginal 0 Condrwa1on 0Correneo <br />County <br />HALL <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />TIFFANY PENDERGRAFT <br />3126 WESTSIDL ST <br />GRAND ISLAND NE 68803 <br />Tax Program i Tax Period <br />1 <br />Date of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costs <br />Total Duc <br />Withholding 101/01/2020 - 03/31!2020 <br />05/11/2020 <br />244,43 <br />29.87 <br />45.23 <br />20.00 <br />339.53 <br />Total <br />339.53 <br />I certify That the Nebraska Department of Revenue has coneIle0 wen the laws of the State of Nebraska in determining rhe amount shown to be duo. <br />end that the taxpayer has failed to pay the amount due afar demand. This Notice of State Tax Lien is an etlective lien and serves to continue the priority of <br />the State's's irneresl el the affectpoperly of 1110 layover. <br />sign r _eeac LC/ f©Qtlt Revenue Agent 11/01/2022 402-471-5717 <br />here Reponse a Signature C. ./ Tike Date P!mrte N r <br />(�/ 7. Revenue Supervisor eryrl- <br />AuhonzedScrotum Tile Date <br />4.494.1074 Par 0-2018 Supersedes 4449.1974 P01. 5-2813 <br />