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NEBRA&447'F- <br />Good Life. Great Sew{e. <br />r,Mr,mw w wvww <br />202401197 <br />NE Sec of State - Robert B. Bonen <br />Filing Document #: 2403000692-2 Pages: 1 <br />Debtor Name: PHILIP HAM <br />Filing Date and Time: 03/22/2024 10:39 AM <br />Notice of State Tax Lien <br />This Notice of Slate 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 00 NOT WRITE IN THIS SPACE <br />Nebraska ID Number <br />12140139 <br />Federal D Number <br />474081838 <br />Gen Serial Number <br />12422972 <br />Lien Filed W,lh: <br />Social Security Number <br />XXX -XX -2926 <br />Spouse's Social Security Number <br />NO SPOUSE SSN <br />Kt Ragletet of Deeds ❑county clerk <br />Date of Use <br />March 13, 2024 <br />Lien type: <br />Notional E]Cotnuatlon ©Corrected <br />County <br />HALL <br />Business Name and Location Address <br />Taxpayer Name and Mailing Address <br />PHILIP HAM <br />118 WEST 11TH STREET <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 />Sates <br />06/01/2021 - 12/31/2021 <br />08/08/2023 <br />1,431.99 <br />630.18 <br />216.25 <br />.00 <br />2,278.42 <br />Total <br />2,278.42 <br />I certify that the Nebraska Department of Revenue has complied with the laws of the State of Nebraska in dew rminlag the amount shown to be due, <br />and that the taxpayer has failed to pay the amount due after demand. This Notice of State Tax Lien is an effective filen and serves to continue the priority of <br />t <br />the State's interest In the a�ttadMdLproper y of the taxpayer. <br />sign Revenue Revenue Senior Agent <br />here i n sr__On`tute <br />esI, c7C !Zh.l2 <br />Authorised Signature <br />Title <br />Revenue Senior Agent <br />03/13/2024 402-595-2247 <br />Date mbei <br />4 gel J.,, <br />cxxfe <br />Title Date <br />4494.1974 Rev, 84018 Superseder 4 -94a -1a'* nee.11-20ts <br />