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KAA <br />Good Life. Great Service, <br />01t4M1OM M tltirrn„ <br />202404176 <br />NE Sec of State - Robert B. Evnen <br />Filing Document #: 2408000688-4 Pages: 1 <br />Debtor Name: JORGE 0 BASULTO <br />Filing Date and Time: 08/28/2024 11:10 AM <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 tien.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 INTIM SPACE <br />Nebraska ID Number <br />48959944 <br />Federales <br />NO FEIN <br />Number <br />Lien Serial Number <br />12483215 <br />Lien Flied With: <br />Sochi Security Number <br />XXX,XXa4$63 <br />Spouee't Socia) Security Number <br />NO SPOUSE SSN <br />i:4 aagisier ()Meads 0courky clerk <br />Dela of Uen <br />August 23, 2024 <br />Lien Type:... <br />® original 0Contuwation pconected <br />County <br />HALL <br />Business Name and Location Address <br />Taxpayer Name end Mailing Address <br />JORGE O BASULTO <br />821 S HARRISON ST <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 />Individual <br />2017 <br />01/07/2024 <br />$1,331.00 <br />$332.75 <br />$351.16 <br />$2,014.91 <br />Total <br />$2,014.91 <br />I certify that the Nebraska Department of Revenue has complied with the laws of the State of Nebraska In datsrmkafttg the amount shown to be duce, <br />and that the taxpayer has Ailed to pay the amount due after demartd.This Notice of Stets tax Lien to an effective lien and serves to continue the priority of <br />Ma State's imereet Inthe attecod property of the taxpayer. <br />Sign 73t,a. (J . ,p t t, Revenue Agent 08123/2024 (308)632-1201 <br />here 1 Preparet's Signature Title Oa* Phone Number <br />1 D 4444 Revenue Supervisor 08/23/2024 <br />Authorized Signature Tele Data <br />4.454-1l24 Rat 6-201e Supersedes 4445.1534 Ra. 114013 <br />