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03/14/2012 WED 15:21 FAX 4p2 471 4429 UCC SECRETARY OF 5TATE ~~~ aall <br />�' <br />� <br />20120195G <br />STATE TAX LIEN ❑ NEBRASKA DEPARTMENT OF LABOR <br />■ Oiucnv�. <br />�002/004 • <br />NDOL Office of Legal Counsel <br />P.O. Bog 94b00 <br />Lincoln, NE 68509-4600 <br />Telephone - (402) 471-9912 <br />FAX - (402) 471-9917 <br />Employer or � <br />Liable Person: 313 Caf� & Cream inc. <br />Address: 313 W. 3 St. Grand Island NE 68801 <br />NDOL Serial No.: LAB-O 115-2012 To be iiled with the Re ister of Deeds in the followin Couaties: <br />NDOL Acct No.: 0339638001 Hall <br />Federal ID No. / SSA No.: 27-042?823 <br />This St�te Tax Lien is issued for unpaid combined taxes (Ne6. Rev. Swt. §§48-657 and 48-664) or payments in lieu of coutrlbuflons (Neb. Rev. Sta[ §AS-660.01) pursuant <br />to the Unifotm State Tax Lien Registretion & Enforcemeat Acc (Neb. Rev Sta� §7� 39Q1, et seq.), Nodce is given that com6ined tsxes or payments in lia► of <br />coMcibudons, interes� (computed at 1.5% per month), and penalties are due from this employer or person and remain uapaid after d�d. These com6iaed taxes or <br />payments in lieu of contributions constitute a lien for azry aad afl personel properiy and real propecty in the co�mty/counties named. belonging to the employer or person. <br />whether now owned or hereafter acquired. _ <br />Qtr. / Yr. Date Assessed <br />2/201 l 2/24/2012 <br />312011 2/24/2012 <br />Combined Tag Or Payment In L"teu <br />Of Contributioas Due <br />. Interest <br />Penalty Through Subtotal <br />3/10/2012 , <br />$165.86 <br />$93.07 <br />TOTAL Combined Tax or Payment in Lieu of Contributions Due (uader this lien only): <br />25.00 $18.23 <br />$0.00 $6.01 <br />$ 209.09 <br />$ 94.08 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 308.17 <br />I certify t6at the Nebraska Department of Labor 6as complied with t6e Employment Security Law of the State of Nebraska in the <br />determination of the amount due, and the employer or person has failed to pay the amount due after demand. <br />CATHERI1�iE D. LANG <br />Commis ' of Labo <br />Date: March 14, 2012 � �Y= <br />JOHN . , Agency Legal Counsel <br />T:�DOCUMENTS�FORMS�I lien.docx THO A. UKIN5KI, Legal Counsel <br />RETURIV FILED COPIES TO: Nebr. Dep� of Labor - LEGAL <br />P.O. Box 94600 <br />Lincoln, NE 68509-4600 <br />NEBR, DEPT. OF LABOR � <br />CHARGE ACCT #1476 <br />