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l- 6an. Sam W Number 1 Lien ry- <br />Qri9inai <br />Ronewai <br />NebTDSka I.D. No counly <br />4515285 Hall <br />BUStNBSS NAME I <br />Buswe" Natrte <br />k' 3efferson Repair <br />z street Addre l6 <br />f <br />Lien <br />Notice of State Tax Lien <br />*ROW irlatruc[iae on reverse aide <br />5ociahSKUrlty Number <br />86 485 - 7772 <br />led with Spouse %Social Securtty <br />Bitter of D*Ws Number <br />unto Clark _ <br />or Ofhea Mailing Address <br />86-400347 <br />1ME AND <br />346 North Jef erSOn state <br />city -- State Zip Code City <br />Grand Island, NE 68801 Grand Island NE <br />This Notice of State Tax Lien is issued by the Nebraska Mpartment of Revenue for unpaid taxes pursuant to the <br />revenue laws of the state of Nebraska Notice is hereby given that taxes including penalties and interest, which are <br />shown blow, sre due from the taxpayer specified above and remain unpaid after demand. These taxes constitute <br />ittr real and deal belonging to the taxpayer a hereafter acquired. <br />a lien in the couttty p� lnoPefi <br />R81 <br />jt,. TOTAL ( S 202.92 <br />bm <br />1 Mreby certf font the Nebraska Department of Revenue has compiled with the revenue laws of the State of Nebraska in the deter - <br />minah- oft mount chd to be due, no the taxpayer has failed to pay the amount due alter demand- II this Notice of State Tax <br />Lien is an fon u1 an ell live lien arvei to continue the priority of the Stale's interest in tM affected property of the taxpayer. <br />Revenue Agent <br />Till • Date <br />as re <br />Special Agent <br />" Title Data <br />tharized Sign • <br />FOR COUNTY OFFICIAL'S USE - --� <br />NEBRASKA DEPARTMENT OF REVENUE -- Whiw and Goldenrod Copies <br />TAXPAYER — Pink Copy <br />1� <br />L_ <br />COUNTY OFFICE — Canary Copy <br />4. 494.74 Rev. 7.81 <br />Supersedes 4. 494.74 Rev. 5.90 <br />1 <br />I <br />