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I I~.b'.sl<. _i1rtment of revenue U.n S.rtal Number Notice of State Tax Lien r 4/05/063 Lien Type ~ Orl91r;al o Renewal Date . Read instructions on rev..... side Social Security Number 5-29-84 505-64-0430 Hall 84~.-o!l 002900 2319101 Lien Flied With Spouse's Social Security 00 Register of Deeds Number Qg County Clerk BUSINESS NAME AND LDCATIDN ADDRESS County Nebraska 1.0. No. TAXPAYER NAME AND MAILING ADDRESS Business Name Name- H Street Address State Zip C6de- City This Notice of State Tax Lien is issued by the Nebraska Department of Revenue for unpaid taxes PUrslWlt to the revenue laws of the slate of Nebraska, Notice is hereby given that taxes including penalties and.interest,whiehare shown below, are due from the taxpayer specified above and remain unpaid after demand. These taxes constitute a lien in the county for real and personal property belonging to the taxpayer or hereafter acquired, TilIX Period Date of Amount of Tax Penalty lnt.r. Additions Balal1c>!of Assessment .A--.ment:Du. 07-01-83 thru 01 107-31-83 5-25-84 94.28 5.00 10.05 109 I 09-01-83 thru 01 109-30-83 5-25-84 71.78 5.97 82 , 10-01-83 thru 01 110-31-83 5-25-84 72.36 5.16 82.52 I --i TOTAL $ 274.60 I hereby certify that the. Nebraska Department of Revenue has complied with the revenue laws of the State of Nebraska in the deter- mination of the amount shown to be due. and the taxpayer has failed to pay the amount due after demand. If this Notice of State Tax Lien is an extension of an effective lien it serves to continue the priority of the state's interest In the affected property of the taxpayer. sign 0A~ ~ "ere'. .~.'.:S ~ . -.'c '-.f rJ-- Authorl gOIl. Revenue Agent 5-29-84 Date Title Special AQent TItle 5-29-84 Date FOR COUNTY OFFICIAL'S USE NEBRASKA DEPARTMENT OF REVENUE - White and Goldenrod Copies TAXPAYER -- PInk Copy COUNTY OFFICE - Canary Copy 4.494--74 Rev. 7-81 Supersedes 4-494-74 Re.... 5-80 u L L ~ L