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NEEIRAG-1474— <br />Good Life. Great Service. <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2304000287-4 Pages: 1 <br />Debtor Name: SEDATION DENTISTRY OF GRAND ISLAND <br />Filing Date and Time: 04/06/2023 09:49 AM <br />Notice of State Tax Lien <br />202301640 <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 Hen. 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 />11249684 <br />Federal ID Number <br />461185506 <br />Lien Serial Number <br />123 15884 <br />Lien Filed With. <br />Register of Deeds © County Cleft <br />Social Security Number <br />NO SSN <br />Spouse's Social Security Number <br />NO SPOUSE SSN <br />Dale of Lien <br />Mardi 29, 2023 <br />Llen Type: <br />® Original 0 Continuation ©Corrected <br />County <br />HALL <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />SEDATION DENTISTRY OF GRAND ISLAND PC <br />908 N HOWARD AVE STE 106 <br />GRAND ISLAND NE 68803 <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 />01/01/2019 - 12/31/2019 <br />06/01/2020 <br />.00 <br />25.00 <br />130 <br />.00 <br />26.30 <br />Sales <br />01/0112020 - 12/31/2020 <br />06/15/2021 <br />75.00 <br />32.50 <br />5.24 <br />.00 <br />112.74 <br />Withholding <br />10/01/2019 -12'3112019 <br />06/24/2020 <br />13.36 <br />38.89 <br />10.81 <br />.00 <br />63.06 <br />Withholding <br />04/01/2020 - 06/30/2020 <br />06/15/2021 <br />385.51 <br />108.11 <br />47.00 <br />.00 <br />540.62 <br />Withholding <br />07/01/2020-09/30/2020 <br />06/15/2021 <br />451.91 <br />236,25 <br />42.10 <br />.00 <br />730.26 <br />Withholding <br />I0/01 2020 - 12/31/2020 <br />06/15,2021 <br />675.00 <br />168.75 <br />46.89 <br />.00 <br />890.64 <br />Total <br />2,363.62 <br />I certify that the Nebraska Department of Revenue has complied with the laws of the State of Nebraska in determining the amount shown to be due, <br />and that the taxpayer has failed to pay the amount due alter demand, This Notice of State Tax Lien Is an effective lien and serves to continue the priority of <br />the State's Interest In the affected property of the taxpayer. <br />sign kbo,.,soo:. V,t„�,(�(j Revenue Agent <br />here Praparer a gnat T',le <br />Revenue Supervisor <br />Autha ed Signature rile <br />03/22/2023 402-471-5723 <br />Date <br />Ph/3/Ntber <br />32m'023 <br />Date <br />4.4944974 Pm, 6 -sate Supersedes 44494974 9w.42613 <br />