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11/02/2012 FR= 12:43 FAX 402 471 4429 UCC SECRETARY OF STATE -�-�� Hall <br />� <br />� <br />�0�2U92�3 <br />B0.LfiMY <br />Filed; 1 <br />�� n ca�c - ucc sn <br />Pes: 1 <br />12 10:46 pM <br />STATE TAX LIEN o NEBRASKA DEPARTMENT OF LASOR �OL Office of Legal Counsel <br />P.O. Boz 946Q0 <br />Lincoln, NE 68509-4600 <br />■ O�t1GINAI. Telephone - (402) 471-9912 <br />FAX - (40Z) 471-9917 <br />Employer or <br />Liable Person: John Bellam <br />Address: 3I 11 College St. Apt 80 Grand Island NE 68803 <br />NDOL Serial No.: LAB-0428-2012 To be file� with the Re ' er of Deeds in the followin Counties: <br />NDOL Acct. No.: 0305419007 Hal] <br />Federal ID No. / SSA No.: aotx-aot-7512 <br />This 5tete Tax Lien is issued for unpaid combined taxes (Neb. Rev. Stat §§48-657 and 48-664) or payments ia lieu of conoributions (Neb. Rev. Star. §48-660.01) pursuent <br />to the Uniform State. Tax Lien Regishation & Enforcement Act (Neb. Rev Stat. §77-3901, ee seq.). Notice is given that combined taxes or payments m lieu of <br />contributions, interest (computed at 1.5% per month), and penalties are due from this employer or person aad remain unpaid after demand. These combined taxe.s or <br />paymenL� in lieu of contributions coasti�ute a lien far any aad all personal property and real property in the cnuntylcoundes named, belonging w the employea or person. <br />whether now owned or hereafter acquired. ` <br />Qtr. / Yr. <br />3f2007 <br />4/2007 <br />2/2008 <br />TOTAL Combined Tax or Payment in Lieu of Contr[butions Due (under t6is lien only): <br />Date Assessed <br />8/23f2012 <br />. 8/23/2012 <br />8/23/2012 <br />8/23/20I2 <br />Combined Tax Or Payment In Lieu <br />Of Contributions Due <br />$730.00 <br />$1,080.00 <br />$1,080.00 <br />Interest <br />Penalty Throagh Subtotal <br />10/31/2012 <br />$25.00 <br />$25.00 <br />$25.Q0 <br />�002/002 <br />27 <br />.78 <br />826.88 <br />$1,562.27 <br />$2,028.78 <br />$1,980.86 <br />$1,931.88 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />S 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$7,503.79 <br />I certify that the Nebraska Department of Labor has complied with the Employment Secarity Law of the State of Alebraska in the <br />determination of t6e amount due, and the employer or person 6as failed to pay the amount due after demand. <br />CATHERINE D. LANG <br />Commissioner o or <br />Date: I 1/2/2012 By: <br />� . BIN, Agency Legal Counsel <br />T:�DOCUMENTS�FORMSU.iens\Original lien.docx MAS A. UKYNSICY, Legal Counsel <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL NEBR DEPT. OF LABOR <br />r.o. Box 94600 CHARGE ACCT #14765 <br />Lincoln, NE 68509�1600 /�� <br />r� <br />