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fnnnclr <br />N.��.; arc <br />Good 1.4. Great Service. <br />NE Sec of State - Robert B. Evn2 <br />Filing Document #: 2305000120-9 Pages: 1 <br />Debtor Name: SHAWN CLOVER <br />Filing Date and Time: 05/03/2023 09:38 AM <br />' �1 7 3 <br />Notice of State Tax Lien <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 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 />13205862 <br />Federal ID Number <br />822621380 <br />Lien Serial Number <br />12316588 <br />Lien Filed With: <br />® Register of Deeds ❑ County Clerk <br />Soaal Security Number <br />XXX -XX -3336 <br />Spouse's Social Security Number <br />NO SPOUSE SSN <br />Date of Lien <br />April 25, 2023 <br />Lien Type: <br />10/01/2022 <br />3,712.00 <br />County <br />HALL <br />K1 Original 0 Continuation <br />111 Corrected <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />SHAWN CLOVER <br />D/B/A TOTAL ECLIPSE <br />305 N BROADWELL AVE <br />GRAND ISLAND NE 68803-4752 <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 />10/01/2021 -06/30/2022 <br />10/01/2022 <br />3,712.00 <br />742.40 <br />141.35 <br />.00 <br />4.595.75 <br />Sales <br />07/01/2022 - 11/30/2022 <br />02/21/2023 <br />2,900.00 <br />580.00 <br />62.80 <br />.00 <br />3,542.80 <br />Waste Reduction <br />07/01/2019 - 06/30/2021 <br />12/06/2021 <br />50.00 <br />10.00 <br />2.48 <br />.00 <br />62.48 <br />Total <br />8.201.03 <br />sign <br />here <br />I candy 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 Inc taxpayer has tailed to pay the amount due after demand. This Notice of State Tax Lien is an effective lien and serves to continue the priority of <br />y <br />(tin State's intereted p rtf the taxpayer. <br />\' ` Revenue Agent 04/25/2023 402-370-3334 <br />Preparer's Signature _ ..-- Title Date P Number <br />r _ _ Revenue Supervisor /7/.,,c -,....A.--3 <br />Authorized Signature <br />Title <br />Date <br />4-494-1974 Rev, 8.2018 Supersedes 4949.1974 Rev 8.2013 <br />