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rebraska <br />emtnt <br />of revemre <br />Notice of State Tax Lien <br />t Aearl .n .. - lone nn .awsa .kr_ <br />Lien Serial Number <br />Lien Type <br />Data <br />Social Security Number <br />Penalty <br />Interest <br />Additiorts <br />[� Original <br />4-0 -84 thru <br />5/01/142 <br />[j Renewal <br />1 -28 -85 <br />507 -38 -3458 <br />01 <br />a� <br />�� ��� nO A �'J.'. <br />v ^j 21 <br />Nebraska I.D. No. <br />County <br />Lion Filed With <br />Spouse's Social Security <br />4753488 <br />Hall <br />C Register of Deeds <br />X] County Clark <br />Number <br />BUSINESS NAME AND LOCATION ADDRESS <br />TAXPAYER NAME AND MAILING ADDRESS <br />Business Name <br />Name <br />5 -31 -84 <br />Dos Banditos of Grand Island <br />Don Gilbreath <br />25.98 <br />Street Address <br />Street or Other fdalring Address <br />609 S. Locust <br />160 Fairway Lane <br />City State <br />ZIP Code <br />City <br />State Zip Code <br />Grand Island, NE <br />_ 68801 <br />Fort Collins, <br />CO 80525 <br />This Notice of State Tax Lien is issued by the Nebraska Department 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 />Awn below, are due from the taxpayer specified above and remain unpaid after demand. These taxes constitute <br />a lien in the county for real and personal property belonging to the taxpayer or hereafter acquired. <br />Tax <br />! NC Y <br />I Tax Period <br />Data of <br />A>gassmertt <br />Amount of Tax <br />Penalty <br />Interest <br />Additiorts <br />Balance of. <br />Assessment Ow <br />4-0 -84 thru <br />01 <br />4 -30 -84 <br />-1 -84 <br />-0- <br />-0- <br />28.66 <br />28.66 <br />05-01-84 thru <br />31 <br />5 -31 -84 <br />1 -2 -84 <br />839.89 <br />25.98 <br />i 69.90 <br />935.77 <br />-01 -84 thru <br />01 <br />6 -30 -84 <br />1 -2 -84 <br />861.01 <br />1 26.63 <br />61.75 <br />949.39 <br />7 -0 -84 thru <br />01 <br />b7 -31 -84 <br />1 -12 -84 <br />960.58 <br />-- - -- <br />29.71 <br />57.48 <br />1,047.77 <br />8 -01 -84 thru <br />-- <br />01 <br />-31 -84 <br />1 -12 -84 <br />1,045.22 <br />32.33 <br />.1 28.87 <br />1,106.42 <br />-01 -84 thru <br />01 <br />09 -30 -84 <br />1 -12 -84 <br />849.97 i <br />26.29 <br />30.97 i <br />_ <br />f <br />907.23 <br />TOTAL <br />S 4,975.24 <br />• •vcv> �err••y roar rnv ry eC".— u"arim ant or fi ev¢nil¢ has compiled with the revenue laws of Ine State of Nebraska in he deter• <br />mtnatlon o} the .'mount shown to be due. and the taxpayer has failed to Pay the amount due after demand. If this Notice of State Tax <br />Lien Is an extension of an effect Iva Ii an it SetyeS to Continua the priority of the state's interest in the affected property of the taxpayer. <br />44 1 <br />Sign } b- Revenue Agent 1 -28 -85 <br />�`rs Prtputr'351 ra Date <br />i• M 'l <br />_ Special Agent 1 -28 -85 <br />Atathorlrtd SiyMt Till.' Date <br />FOR COUNTY OFFICIAL'S USE <br />NEBRASKA DEPARTMENT OF REVENUE -- White and Goldenrod Copies <br />W <br />TAXPAYER -- P,nk Copy COUNTY OFFICE - Canary COpy <br />4.44"44 Rav, 7-61 <br />supersenos 4..194.'1 Rev. S�eO <br />��1 <br />