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Gari t.i€e ,real Service, <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2306000612-4 Pages: 1 <br />Debtor Name: BURGOS QUEEN MEXICAN FOOD LLC <br />Filing Date and Time: 06/23/2023 10:06 AM <br />Notice of State Tax Lien <br />202303137 <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 lien. 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 />15005895 <br />Federal ID Number <br />852099193 <br />Lien Serial Number <br />12317495 <br />Lien Filed With <br />0 Register of Deeds ❑County Clerk <br />Social Security Number <br />NO SSN <br />Spouse's Social Security Number <br />NO SPOUSE SSN <br />Dale of Lien <br />June 19, 2023 <br />Lion Type: - <br />oconxied <br />County <br />HALL <br />1;i Original ■ Contbtr alion <br />Business Name and Loca <br />on Address <br />Taxpayer Name and Mailing Address <br />BURGOS QUEEN MEXICAN FOOD LLC <br />2610 S LOCUST ST <br />GRAND ISLAND NE 68801 <br />1`ax Program <br />Tax Period <br />Date of <br />Assessment <br />Tax <br />Penalty <br />Interest <br />Costs <br />Total Due <br />Saks <br />04/01/2022 - 06/30/2022 <br />01/03/2023 <br />1,676.19 <br />.00 <br />72.42 <br />.00 <br />1,748.61. <br />Sales <br />07/01/2022 - 09/30/2022 <br />01/03/2023 <br />6.036.75 <br />603.68 <br />176.32 <br />.00 <br />6,816.75 <br />Sales <br />10/01/2022 - 12/31/2022 <br />03/01/2023 <br />2,878.08 <br />287.81 <br />59.14 <br />.00 <br />3,225.03 <br />Sales <br />01/01/2023 - 03/31/2023 <br />05/01/2023 <br />3,396.78 <br />339.68 <br />27.92 <br />.00 <br />3,764.38 <br />Total <br />15,554.77 <br />I certify that the Nebraska Department of Revenue has comptied with the laws of the Skate of Nebraska in dote mg the amount Shown to be due. <br />and that the taxpayer has tailed to pay the amount due after demand. This Notice of Stake Tax Lien is an eltecdtve tier and serves to continue the priority of <br />the State's interest hi the affected property of the taxpayer. <br />sign pat '7i2a,.r.. - <br />here Preparers S' Inat�..„.;--� <br />Authors d Sictnaturee <br />Revenue Tax Specialist Senior 06/12/2023 402-471-6067 <br />Title Date Phone Number <br />Revenue Supervisor 6/20/2023 <br />Title Date <br />4-.194.1974 Rp. a -sole Superseden e -949.197e Rev, 1.3013 <br />