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Qtr. / Yr. <br />Date Assessed <br />Combined Tax Or Payment In Lieu <br />Of Contributions Due <br />Penalty <br />Interest <br />Through <br />11/29/2012 <br />Subtotal <br />2/2012 <br />9/6/2012 <br />$213.33 <br />$0.00 <br />$12.73 <br />$ 226.06 <br />3/2012 <br />11/14/2012 <br />$74.14 <br />$25.00 <br />$1.06 <br />$ 100.20 <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 />TOTAL Combined Tax or Payment in <br />Lieu of Contributions Dn. Innelpr this lion itnh, • <br />a 'VIZ •Ic <br />12/14/2012 FRI 15:27 FAX 402 471 4429 UCC SECRETARY OF STATE --*-. Hall (2008/009 <br />of) <br />STATE TAX LIEN ❑ NEBRASKA DEPARTMENT OF LABOR <br />■ ORIGINAL <br />NDOL Office of Legal Counsel <br />P.O. Box 94600 <br />Lincoln, NE 68509 -4600 <br />Telephone - (402) 471 -9912 <br />FAX - (402) 471 -9917 <br />Employer or <br />Liable Person: Chan C. Yim _ <br />Address: 1709 Bass Rd. Grand Island NE 68801 <br />NDOL Serial No.: LAB- 0475 -2012 <br />NDOL Acct. No.: 1 0331662001 <br />Federal ID No. / SSA No.: fxxx -xx -1323 <br />This State Tax Lien is issued for unpaid combined taxes (Neb. Rev. Stat. § §48 -657 and 48 -664) or payments in lieu of contributions (Neb. Rev. Stat. §48- 660.01) pursuant <br />to the Uniform State Tax Lien Registration & Enforcement Act (Neb. Rev. Stat. §77 -3901, et seq.). Notice is given that combined axes or payments in lieu of <br />contributions, interest (computed at 1.5% per month), and penalties are due from this employer or person and remain unpaid after demand. These combined taxes or <br />payments in lieu of contributions constitute a lien for any and all personal property and real property in the county /counties named, belonging to the employer or person, <br />whether now owned or hereafter acquired. <br />I certify that the Nebraska Department of Labor has complied with the 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 />CATHERINE D. LANG <br />Commissioner of Labor <br />Date: December 14, 2012 <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL <br />P.O. Box 94600 <br />Lincoln, NE 68509-4600 <br />2012/0674 <br />To be filed with the Register of Deeds in the following Counties: <br />Hall 1 <br />By: <br />NE Sec of Stake John A <br />9912704649 -7 <br />YIM CHPIJ C. <br />Filed: 12/14/2012 <br />- <br />ALB IN, Agency Legal Counsel <br />T-IDOCUMENTS\FORMSU,iens \Original lien.docx TH ! AS A. UKINSKI, Legal Counsel <br />Gale - UGC <br />Pgs: <br />11:02 PM <br />STL <br />NEBR. DEPT. OF LABOR <br />CHARGE ACCT. #147 <br />