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r <br />M <br />1- --7 " <br />Notice of State Tax Lien <br />Uen Serial Number <br />Lien Type <br />Date <br />Social Saeurlty Number <br />- '02497 w <br />Balance of <br />A> mt Due <br />❑ Ofiglnal <br />-01 -83 thru <br />U <br />4102/605 <br />12 R-n -wal <br />2 -3 -84 <br />505 -50 -9386 <br />5.20 <br />Ne6gaRa I.D. No. <br />County <br />Lion Filed With <br />Spouse's Social Security <br />0 -01 -83 thru , <br />110 -31 -83 9 - -84 131.59 <br />5.00 <br />X] Register of DWI <br />Number <br />140.12 <br />2751 380 <br />Hall <br />&J County Cferk <br />BUSINESS NAME AND LOCATION ADDRESS <br />TAXPAYER NAME AND MAILING ADDRESS <br />Busineu Memo <br />— 5.00 _ <br />Name <br />Safari Bar & Lounge <br />156.32 <br />Verlie G. Johnston <br />Street Addrae .� <br />i- <br />Street or Other Mailing Address <br />106 East 2nd Street <br />157.34 <br />803 Shady Bend Road <br />City state <br />zip code <br />City State zip Code <br />Grand Island, NE <br />68801 <br />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 />Amu below, are dire from the taxpayer specified above and remain unpaid after demand. These taxes constitute <br />alien in the county for real and personal property belonging to the taxpayer or hereafter acquired. <br />ax <br />comwv <br />Number <br />Date of <br />Tax Period Amount of Tax <br />`T— <br />Penalty ( <br />interest <br />( Additions <br />Balance of <br />A> mt Due <br />-01 -83 thru <br />01 <br />109-M-83 12 -3 -84 168.12 <br />5.20 <br />6.51 <br />179.83 <br />01 <br />0 -01 -83 thru , <br />110 -31 -83 9 - -84 131.59 <br />5.00 <br />3.53 <br />140.12 <br />{T1 -01 -83 thru j <br />01 <br />11 -30-83 2.3 -84 14,9.03 <br />1112-01-83 <br />— 5.00 _ <br />2.29 <br />I <br />156.32 <br />01 <br />thru I j <br />i- <br />157.34 <br />1 <br />TOTAL <br />I $ 633.61 <br />t heeeby certify tnat the r4.0,4 xa L1- 4a1tment o/ fievenue eras i mpbBO with the !®venue Ia.$ of the State of Nebraska in the dater. <br />net on pt the amount Snopn tcd G& Cu*. and the taepayer nay failed 1, pay the amount due after demand. if this Notice of State Tax <br />Lien is an eat -ndlon at an effeclnye 0 serves i —nnntnt the uriunty of the states interest In the aff -tiled property of ill* taXQayet. <br />silo, ' Yi�2 Revenue Agent 5 -22 -85 <br />hefo ...... eparer'a we -.tie Date <br />ape <br />_ Agent 5 -22 -85 <br />Amtnorisa®S ure 7Mis Date <br />_-------- -- ..— __.. -_ <br />q FOR COUNTY OFFICIAL'S USE <br />S"ASKA DEPARTMENT OF REV ENUE - White and Goo.lonrod Chpies <br />TAXPAYER Pink Copy <br />IN <br />a <br />COUNTY OFFICE; _. Canary Ctpy <br />a 41Aa Ja stem. l,eI <br />- .rsp4,$e,J&s a dgd ld !tam, 5 ad <br />al <br />