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03/14/2012 9dED 15:22 FAx 402 471 4429 UCC SSCRETARY OF STATE -�y-� Hall <br />�, <br />, <br />201201957 <br />I�003/004 <br />NE See of S�eie John A Gale - YGC 5' <br />9912687493-4 Pas: 1 <br />SHELDON COREY <br />Ftled: D3/14/2012 11:28 RT7 <br />STATE TAX LIEN ❑ NEBRASKA DEPARTMENT OF LABOR <br />■ ORIGIlWeiI. <br />1�TDOL Office of Legal Counsel <br />P.O. Bog 94600 <br />Lincoln, NE 68509-4600 <br />Telephone - (402) 471-9912 <br />FAX - (402) 4� 1-9917 <br />L�mployer or <br />Liable Person: Corey Sheldo <br />Address: 313 W. 3 S`t. Grand Islartd NE 68801 <br />NDOL Serial No.: LAB-U I 142012 To be filed with the Re 'ster of Deeds in the foUowin Counties: <br />NDOL Acct No.: 0339638001 Hall <br />Federal ID No. / SSA No.: �aoc-xx-6539 <br />This State Tax Lien is issued for unpeid com6ined taxes (Neb. Rev. Smt. §§48-657 and 48-664) or payments in lieu of contributions (Neb. Rev. Stat. §48-&60.01) pursuant <br />to the Uaiform State Tax Lien Regisiration & Enforcement Act (Neb. Rev Stat §77 3901, et seq.), Notice is givea that combined taxes ar payments in lieu of <br />contri6u6ons, interest (camputed at 1.5% per month� and penalties are due from this employet or person end remain unpeid aftea demand. These combined taxes ot <br />peyments in lieu of con6ibutions constitute a lien for aay and all personal properly and real property in the county/coundes named, belonging to the employer or persoq <br />whether now owned or hereafter acquired. <br />Qtr. / Yr. Date Assessed <br />2/2011 2/24/2012 <br />3/2011 2/24/2012 <br />Combined Tax Or Payment In Lieu <br />Of Contributions Dne <br />$165.86 <br />$93.07 <br />TOTAL Combined Taz or Payment in Lieu of Contributions Due (under t6is lien only): <br />Interest <br />Penatty Through Snbtotal <br />3/10/2012 <br />$25.00 $1823 <br />$0.00 $6.01 <br />$ 209.09 <br />$ 99.08 <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 />S 308.17 <br />I certify that the 1�lebraska Department of Labor has complied with the Employment Security Law of the State of Nebraslca in the <br />determination of the amount due, and the employer or person has failed to pay the amount due after demand. <br />CATHERINE D. LANG <br />Date: March 14, 2012 <br />T:�DOCUMENTSIFORMS1LienslOriginal lie�.docx <br />By: <br />�LB�fi, Agency Legal Coansel <br />A. UKINSKI, Legal Counsel <br />� <br />I <br />RETURN FILED COPIES T0: Nebr. Dep� of Labor - LEGAL NEBR DEPT. OF LABOR ; <br />P.O. �ox 9460o CHARGE ACCT #147 (� 3 . <br />Lincoln, NE 68509-46110 ` ��) J� <br />