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11MUrrent a*a <br />Notice of State Tax Lien <br />Ltan Serial Number <br />Lien Type <br />Date <br />Social Security Number <br />Interest <br />5/01/143 <br />(� original <br />L Renewal <br />1 -28 -85 <br />507 -38 -3458 <br />' <br />{ 000463 <br />Nowaska I.D. No. <br />County <br />Lien Filed With <br />Spouse's Social <br />Security <br />1 -2 -84 <br />310.62 <br />)0 Register of Deed <br />Number <br />336.75 <br />4753488 <br />Hall <br />Hall <br />fo County Clerk <br />- -- <br />I <br />9USINESS NAME AND LOCATION ADDRESS <br />TAXPAYER NAME AND MAILING ADDRESS <br />swine" Name <br />Name <br />Dcts BanslitoS of Grand Island <br />Don Gilbreath <br />Street Address <br />J <br />Street or Other Mailing Address <br />609 S. Locust <br />160 Fairwa Lane <br />city State <br />Zip Code <br />City State Zip Code <br />Grand Island NE <br />68801 <br />1 Fort Coll -ins, 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 lays of the state of Nebtaska. Notice is hereby given that taxes including penalties and interest, which are <br />shown below, arc due from the taxpayer specified above and remain unpaid after demand. These .taxes constitute <br />a lien in the county for real and personal properly belonging to the taxpayer or hereafter acquired. <br />Tax <br />CaMEoty E Tax Parfait <br />Nurnber 3 <br />' Dote of <br />Assessment <br />Amount of Tax <br />I <br />i Penalty <br />l <br />Interest <br />Additions <br />Balance of <br />Asc�ttent Ow <br />21 P§-30-84 <br />11-2-84 1 -2 -84 <br />I 407.97 <br />81.59 <br />28.32 <br />517.88 <br />7 -01 -a4 thru <br />21 1J -30 -84 <br />1 -2 -84 <br />310.62 <br />15.53_ <br />10.60 <br />336.75 <br />I <br />- -- <br />I <br />i <br />J <br />TOTAL <br />s 854.63 <br />I hareoy Certify that the Nebraska Department of Revenue has Compiled with the revenue laws of the State of Nebraska in the dater - <br />mination of the amount shown to be due, and the taxpayer ties failed to pay the amount due attar demand. It this Notice of State Tax <br />Lien Is an extension of an effective Ilan It serves to Continue trio priority of the statu's interest in the affected property of the taxpayer. <br />sign III, Revenue Agent 1 -28 -85 <br />�® aparer's 'ture Title Oste <br />. Special Agent 1 -28 -85 <br />Authorised S ature Title Date <br />FOR COUNTY OFFICIAL'S USE <br />NEBRASKA DEPARTMENT OF REVENUE — White and Goldenrod Copies TAXPAYER - Pink Copy COUNTY OFFICE -- Canary Copy <br />a.aea-fa Rev. %ai <br />5upeiaaes•1494-74 Ray.': -no <br />Li <br />R <br />