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a <br />sska <br />Notice of State Tax Lien <br />of revenue <br />*Read instructions on reverse side <br />L1 @n 5°1131 Number Lien TYDO Dato Social Sec url[y Number <br />K Original <br />5/04/486 ❑ Renewal 4 -8 -85 506 -20 -4855 <br />Nebraska I.D. No. County Lien Filed With spouse's social security <br />4756665 Hall Register Pf 0-cis Number Q01741 <br />i lxl County Clark 291 -18 -2387 �5"� <br />BUSINESS NAME AND LOCATION ADDRESS TAXPAYER NAME AND MAILING ADDRESS <br />Business Name <br />I. K. Bootery N8O1p <br />street Add, 0A -- <br />Irene & Walter Ko yst nsky d /b /a I. K. Bootery <br />Grand Island Mall street or Other Mailing Address <br />City <br />411 No_ ._Grace <br />state Zip Code -- <br />Grand Island, C1fy state zip codo <br />NE _ 68801 — Grand Island,_ _ NE 68801 <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 />Tax <br />Category I , Amount of Tax <br />Number Assessment PanaltY Interest Additions —_T— Balance of <br />I09 -01 -84 thru — F - - -- Assemnent Due <br />01 109 -30 -84 2 -8 -85 ! 95.92 5,98 ! 7.87 109.77 <br />10 -01 -84 thru <br />01 10 -31 -84 2 -8- _8125.99 5.00 _ 6.47 _ I 137. 46 <br />11 -01 -84 thru <br />01 11 -30 -84 �2 8 <br />- -85 108.30 -0 .00 4.31 117.61 <br />1 -84 thru �l 5 5 —1 - <br />-31 -84 ! - -8 -85 140.89 1___5.00_ -+ -3.94 1 149.83 <br />-01 -85 thru 1 }- - - - - -- _ <br />-31 -85 3 -27 -85 131.15 1 5.00 I1 2,11 <br />-01 -85 138.26 <br />3 85 13 - ?7 -A5 11 ra �c __ I <br />TOTAL 1 S 716.49 <br />I ,10n ncr@by Of certliy that :he Ns to be j —,a and ih of pave.". has c mplietl with the revenue laws n1 Lien natlOn of the amount .how. t0 be Uu@, and the tax Payer has failed t0 Ina State I, Nebraska in the del.r <br />Lien IS an extension OI an ef}@ctlVe ti . it ser,es to rOnlln u@ the PaY thB amnunt due attar tlem an d. r this Notice Of State Tax <br />PrloritY A the state's I terest I. tn@ a1f@ctetl <br />sign Prnp@rtY "1 the tJSp3Yel. <br />�' <br />here Revenue Agent 4 -9 -85 <br />Tllle <br />oat@ <br />Authorized st tat. .— _ Special Agent 4 -9 -85 <br />Data <br />FOR COUNTY 6FFIc1AL_s USE — _ - - -- <br />NEBRASKA DEPARTMENT OF REVENUE - White and Goldenrod Copies <br />TAXPAYER Pink copy ____ -.- <br />COUNTVpFfICE Ca ary i:npy <br />4- 494.14:1- <br />U <br />L- <br />7 <br />