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nebraska department ~Irr@a.nt.. I Notice of State Tax Lien •Raad -inerntninna nn revorea dAo LIM Serlat Number Uen Type Oate Social Security Number - ®Onginal - 2 12/736 ^ Renewal 12-3-82 / ~ , Neblazka I.D. No. -Caunty ~ Lien Flletl Wlth Spouse's Social Security 1 i / - `~ -R ~ ~ t~ -L r_- S~ Reg7zter of Odetla Number 449$76 Hall ~] cppnty aerk UHCip IARYAY tH NAMC ANU MAILING AUUHGaS Businesf-Name Name Fourth Street Insurance Agency American Owner Operator Str@et Atldresz - Street or Other Malting Address ~ I= t 21st Street. Room 303 City State Zlp Code Clty State Zip Code -Grand Island NE b$801 d n Utah 84401. "Chic Notice oCState Tax Lien is issued by the Nebraska llepaztment of Revenue for unpaid taxes pursuant to the revenue laws of the state 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 Category Number Tax Period Assessment j Raiance of Amount of lax ~ Penalty Interest ~ Additions F Assessment Oue - i 10-01-80 thru ~ - -81 ~ f j 1 943 "~5 7 53 ^R f ~ 2 6a1 83 I I ~ A j ' { i '-__- { ._ TDTAL 4 S ? 601 $3 I hereby certify *-hat the Nebraska Department of Revenue has Complied ~.vitn the revenue Idws o f the State pf Nebraskd in the tlet2r- mination of the amount sho wn to rte due, antl the taxpayer has failed tp pay the amount due after tlemantl, tt this Nv[fca of State Tax Van Is an extensi of an a ft ect e lien it serves to continue the priority of th@ state's interest in [h e a/fa<tev property of the to xpaYar. S~gli ( ~i ~ oL `f ° here Reparer's St9n t} - Special Aaent _ % ~ ~_,.__-_ rice f 12-3-?2 Date J "~ Special Aaent 12-3-8' ' Authorizetl Slgn re '-' Title Date FOR COUNTY OFFICIAL'S USE COUNTY OFFICE -CanaryCopy 4-49474 Rev. 7-81 SUparsotles 4-494-]4 Rev. 5-80 ~.