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N_E BRA6T4A- <br />Gooc life. Great Sery te. <br />IANC ... M 11eVr611Je <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2211000307-8 <br />Debtor Name: LUIS JACOBO <br />Filing Date and Time: 11/08/2022 09:50 AM <br />Pages: 1 <br />Notice of State Tax Lien <br />202207891 <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 11 no <br />continuation statement is recorded on or prior to the expiration of <br />the previous lien or continuation statement. <br />PLEASE DONOTWRITEISMS SPACE <br />Nebraaka ID Number <br />13439146 <br />Federal ID Number <br />843236126 <br />Lien Serial Number <br />12212319 <br />Lien Filed WSW <br />lin %ob. of Deeds ❑ County clerk <br />Social Security Number <br />XXX -XX -2359 <br />Spouses Social Security Number <br />NO SPOUSE SSN <br />Dab of Lien <br />October 7, 2022 <br />Lien Type: <br />0Corrected <br />County <br />HALL <br />0 Original ■ Continuation <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />LUIS JACOBO <br />JACOBO PEREZ ENTERPRISES LLC <br />411 E 4TH APT 1 <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 />Sales <br />09/01/2020-0l/31/2021 <br />03/01/2021 <br />9,997.15 <br />2,131.10 <br />843.77 <br />.00 <br />12,972.02 <br />Saks <br />02/01/2021- 02/28/2021 <br />04/01/2021 <br />6,739.24 <br />473.92 <br />263.26 <br />.00 <br />7,476.42 <br />Sales <br />03/01/2021 .05/31/2021 <br />07/01/2021 <br />9,668.68 <br />1,166.87 <br />405.61 <br />.00 <br />11,241.16 <br />Sales <br />06/01/2021 - 06/30/2021 <br />08/02/2021 <br />.00 <br />393.56 <br />1.94 <br />.00 <br />395.50 <br />Sales <br />07/01/2021 -07/31/2021 <br />09/01/2021 <br />2,071.08 <br />407.11 <br />71.00 <br />.00 <br />2,549.19 <br />Sales <br />08/01/2021 -08/31/2021 <br />10/01/2021 <br />3,046.45 <br />.00 <br />96.29 <br />.00 <br />3,142.74 <br />Sales <br />09/01/202! -09/30.2021 <br />11/01/2021 <br />1,819.75 <br />381.98 <br />53.50 <br />.00 <br />2,255.23 <br />Sales <br />10101/2021 -10/31/2021 <br />12/01/2021 <br />2,687.87 <br />468.79 <br />71,59 <br />.00 <br />3,228.25 <br />Sales <br />11/01/2021 - 11/30/2021 <br />04/19/2022 <br />5,510.00 <br />1,102.00 <br />131.79 <br />.00 <br />6,743.79 <br />Waste Reduction <br />07/01/2020 - 06/30/2021 <br />12/06/2021 <br />25.00 <br />5.00 <br />.74 <br />.00 <br />30.74 <br />Withholding <br />10/01/2021-12/31/2021 <br />03/25/2022 <br />497.87 <br />24.89 <br />8.15 <br />.00 <br />530.91 <br />Total <br />50,565.95 <br />sign <br />here <br />1 certify that the Nebraska Department of Revenue has complied with the laws of the State of Nebraska in determinng the amount shown to be due, <br />and etas the taxpayer has felted to pey the emount due after demand, This Notice of State Tax Lien is an eteeWe ken and serves to continue the priority of <br />the State's interest in the affected property of the taxpayer. <br />lied Sine ure <br />Revenue Tau Specialist Senior 09/30/2022 402-471-6067 <br />Tide Date <br />Revenue Supervisor <br />Phone Number <br />11/1/2022 <br />Tide <br />Dale <br />4-494-1874 Flet. 8.2011 Supersedes 4449.1974 Rev. 8.2013 <br />