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N EBRA&K <br />2023052 3 <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2310000155-7 <br />Debtor Name: SHAWN CLOVER <br />Filing Date and Time: 10/05/2023 08:53 AM <br />Pages: <br />1 <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 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 />Nebraska ID Number <br />13205862 <br />Federal ID Number <br />822621380 <br />Lien Seriat Number Lien Fled With: t-�l <br />12319618 Q Register of Deeds J County Clerk <br />Date of Lien Lien Type: <br />September 29, 2023 l El Original Contin ualion <br />Business Name and Location Address <br />PLEASE DO NOT WRITE IN THIS SPACE <br />Social Security Number <br />XXX -XX -3336 <br />Spouse's Social Security Number <br />NO SPOUSE SSN <br />County <br />Corrected HALL <br />Taxpayer Name end Mailing Address <br />SHAWN CLOVER <br />DiB?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 Total Due <br />Sales <br />12/01/2022 - 03/31/2023 <br />06/25/2023 <br />2,900.00 <br />580.00 <br />82.24 <br />.00 ` 3,562.24 <br />Total 3,562.24 <br />sign <br />here <br />I comfy that the Nebraska Department 01 Revenue has complied with the laws of the State of Nebraska in determining the amount snows to be due. <br />and that the taxpayer has failed to pay the amount due after demand. This Notice of State Tax Lien is art effective lien and serves to continue the priority of <br />Ntr States intortsl to the affected proper of the taxpayer. <br />' k.. V (s, \ .,�;' Revenue Agent 09124/2023 402-370-3334 <br />Parers Si nat+0r , w,_,,, ,. \ i Tithe Dale Phone Number <br />Revenue Supervisor 61,/P .5 <br />Authorized Signatur <br />Title Date <br />4.494.5974 Rev. 8-2916 Superaeoaa 4-949.1974 Rev. 8.2013 <br />