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r Notice of State Tax Lien . Read instructions on reverse side Uen T~pe.-~ !Social Security Number l- 50 Original I. ! o Renewal '10-1 Q-R4 I County ~ Lien Filed With Spouse'S Social Security "4 _ 00561; 5- I LX Register of Deeds Number 0 V - I Q} County Clerk BUSINESS NAME AND LOCATION ADDRESS rAXPAYER NAME AND MAILING ADDRESS Business Name Name ATCHS of Lincoln, Inc. ATCHS of Lincoln, Inc. Street Address Street or Other Malting Address 3123 Stolly Park Road 301 North Cotner NE 68505 Grand Island NE Zip Code 68801 City Lincoln State Zip Code City State This Notice of State Tax Lien is issued by the Nebraska Department of Revenue for unpaid taxes pursuant to the revenue laws of the slate of Nebraska, Notice is hereby given that taxes including penalties and Interest, which are 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. Tax Pel"iod Date of Amount of Tax Penalty Interest Additions Balance of ! Assessmgnt Assessment Oue 520.99 30.14 34.37 585.50 24.20 42.34 849.15 01 1;10.54 ::,-,.d8 __ 2:-.76 655.18 TOTAL $ 2 089.83 I hereby certll'Y that the Nebrdska Departnlent of Revenue ,135 complied with the revenue laws of the State of Nebraska in the detef~ !":lination 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 Loen i, an exlen,ion of an effect, "en" 'e<ve' to conlonue Ihe "nonly 0' Ihe "ate', mte'e" ,n the affected ""(Qj..Of the taxpaye" . .mnne _, ~t:'t,/91'j TItle Hanager . /?-/9tfY Tolle Oat. FOR COUNTY OFFICIAL'S USE NEBRASKA DEPARTMENT OF REVENUE - WhIte and Goldenrod Copies TAXPAYER -- Pink Copy COUNTY OFFICE -- Canary Copy 4-494-74 Rail. 7-81 Supersedes 4-494-74 Rev. 5.80 u L L ~ L