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03/16/2012 FR2 14:42 PAX 4p2 471 4429 UCC 3ECRETARY OF STATE ~~~ xall <br />� <br />O r <br />�/ � <br />O <br />2012021 �.6 <br />---- �„ <br />STATE TAX LIEN ❑ NEBRASKA DEPARTMENT OF LABOR <br />■ O1tIGINAL <br />�oos�ooe <br />NDOL Office of Legal Counsel <br />r.o. �g 9a600 <br />Lincoln, NE 68509-4b00 <br />Telephone - (402} 4�1-9912 <br />FAX - (402) 471-9917 <br />Employer or <br />Liable Person: Cody Terrell White f/d/b/a Sax's Pizza _ <br />Address: 5011 N, 2 Ave. Ste 52 Kearney NE 68845 <br />NDOL Serial 1Vo.: LAB-OI 19-2012 To be f led with the R ister of Deeds in the followin Counties: <br />NDOL Acct. No.: 0336945009 Hall Buffalo <br />Federal ID No. ! SSA No.: 27-2603704/ �cxx-4422 <br />This State Tax Lien is issued for uQpald wmbined taxes (Neb. Rev Swt §§48-659 and 48-664) or payments in lieu of contn`butions (Neb. Rev. Srat $48-660.01) pwsuant <br />to ffie Unifocm State Tax Lien Registratioa & Enfarcement Act (Neb. Rev Sta[ §77 3901, et seq_). Nudce is given that cambined taxes or payments in lieu of <br />contributians, interest (computed at 1.5% per momh), and penelties are due from this employer or person and remain unpaid after demend. These combined taxes or <br />payments in lieu of cornributians constitute a Gen for any and alI personai property and real property in the county/c;ounties named, belonging to the employer or pelsoon. <br />whether now owned or hereafter acquired. <br />Qtr. / Yr. <br />2/2010 <br />0 <br />1 <br />1 <br />Date Assessed <br />2/23/2012 <br />2/23/2012 <br />2/23/2012 <br />2/23/2012 <br />2/23/2012 <br />$41.65 <br />$505.28 <br />$403.79 <br />TOTAL Combined T�x or Payment in Lieu of Contributions Due (under this lien oaly): <br />Penalty <br />$0.00 <br />$25.00 <br />$25.00 <br />$25.00 <br />$25.00 <br />Interest <br />Through <br />3/9/2012 <br />$12.05 <br />$123.31 <br />$80.22 <br />$67.43 <br />$47.68 <br />Subtutal <br />$ 53.70 <br />$ 653.59 <br />$ 509.01 <br />$ 528.05 <br />$ 508.30 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />52,25z.65 <br />1 certify that the Nebraska Department ot Labor has complied with the Employment Security LHw of the State of Ne6raslca in t6e <br />determination of the amount dae, and the employer or person has failed to pay the amount due after demand. <br />CATHERiNE D. LANG � <br />Commissioner o or � <br />� j . <br />Date: March 16, 2012 BY� � <br />°°= JO�N . $IN;�Agency Legal Connsel <br />T;�DOCUME1vT'S�FOttMSlLiens�Origina� tien.aocx TH011�AS A�,s�KINSKI, Legal Counsel <br />t_/ <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL <br />P.O. Boa 9460Q <br />Liacoln, NE 68509-4600 <br />Combined Tax Or Payment In Lieu <br />Of Contributions Dae <br />NEBR DEPT. OF LABOR <br />CHARGE ACCT. #�.476$� <br />� <br />