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ask a <br />meht <br />of ravenw <br />Notice of State Tax Lien <br />•Read instructions on reverse side <br />Lien Serial Number <br />Lien Type <br />Date <br />Social Security Number <br />Penalty <br />Interest <br />F] Original <br />Balarm <br />Assessment <br />22 <br />t ru <br />12 -31 -76 <br />0/04/432 <br />11 Renewal <br />04 -03 -80 <br />485 -36 -0386 <br />85....0; 000845 <br />Nebraska I.D. No. <br />County <br />Lion Filed With <br />Spouse's Social Security <br />23035110 <br />Hall <br />Register of Dead$Number <br />® County Clark <br />484 -38 -5536 <br />341.44 <br />BUSINESS NAME AND LOCATION ADDRESS <br />TAXPAYER NAME AND MAILING ADDRESS <br />Business Name jorm C. and Constance Crouse <br />Name John C. and constanc-e-r-rouse <br />(Jointly and Severally) <br />(Jointly and Severally) <br />Street Address <br />Street or Other Mailing Address <br />4 G Palmetto Apartments <br />4 G Palmetto Apartments <br />City State <br />Zip Code <br />City State Zip Code <br />Camden, SC <br />29020 <br />Camden, SC 29020 <br />This Notice of State Tax Lien is issued by the Nebraska Department of Revenue for unpaid taxes pursuant to the <br />revenue laws of the state of Nebraska. Notice is hereby given that taxes including penalties and interest, which are <br />shown below, are due from the taxpayer specified above and remain unpaid after demand. These taxes constitute <br />a lien in the county for real and personal property belonging to the taxpayer or hereafter acquired. <br />wul-ui-lb <br />Tax Period <br />Onto of <br />Allsagment <br />Amount of Taz <br />Penalty <br />Interest <br />Additions <br />Balarm <br />Assessment <br />22 <br />t ru <br />12 -31 -76 <br />7 -14 -77 <br />145.80 <br />14.54 <br />160.34 <br />22 <br />- ru <br />12 -31 -77 <br />4 -15 -78 <br />288.00 <br />19.40 <br />34.04 <br />341.44 <br />I <br />� <br />TOTAL <br />$ 501.78 <br />I hereby Certify that trio 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 clue, 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 effective Ilan it Serves to continue the priority of trio slate's interest In the affected property of the taxpayer. <br />•e ' <br />` Revenue Aaent- <br />hers erla Sig ur. la ste <br />- <br />AuliflOrladd Signature Title Date <br />FOR COUNTY OFFICIAL'S USE <br />d _ <br />NEBRASKA DEPARTMENT OF REVENUE -- White and Goitenrod Copies TAXPAYER - Pink Copy <br />COUNTY OFFICE Canary Copy <br />4 49414 Rev, i-al <br />supersedes 4 49444 Rev, 5,ho <br />11K <br />r <br />