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Q tr. / Yr. Date Assessed Combined Tax Or Payment In Lieu Of Contributions Due Penalty Interest Through g 11/29/2012 Subtotal 2/2012 9/6/2012 $213.33 $0.00 $12.73 $ 226.06 3/2012 11/14/2012 $74.14 $25.00 $1.06 $ 100.20 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): $ 326.26 12/14/2012 FRI 15:27 FAX 402 471 4429 UCC SECRETARY OF STATE cf) STATE TAX LIEN ❑ NEBRASKA DEPARTMENT OF LABOR ■ ORIGINAL Date: December 14, 2012 Employer or Liable Person: Tac -Xuan Dip Address: 1709 Bass Rd. Grand Island NE 68801 NDOL Serial No.: 1 LAB- 0476 -2012 NDOL Acct. No.: 1 03 31662001 Federal ID No. / SSA No.: 1 xxx -xx -5679 T: \DOCUMENTSIFORMS\I.iens\Original lien.docx RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL P.O. Box 94600 Lincoln, NE 68509 -4600 201210677 By: Hall 10009 /009 9912 -0 pg s: 1 TAC - XUAtd DIp Filed: 12/14/2012 11:02 AM , Agency Legal Counsel S A. UKINSKI, Legal Counsel NDOL Office of Legal Counsel P.O. Box 94600 Lincoln, NE 68509 -4600 Telephone - (402) 471 -9912 FAX - (402) 471 -9917 To be filed with the Register of Deeds in the following Counties: Hall 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 to the Uniform State Tax Lien Registration & Enforcement Act (Neb. Rev. Stat. §77 -3901, et seq.). Notice is given that combined taxes or payments in lieu of' 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 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, whether now owned or hereafter acquired. I certify that the Nebraska Department of Labor has complied with the Employment Security Law of the State of Nebraska in the determination of the amount due, and the employer or person has failed to pay the amount due after demand. CATHERINE D. LANG Com NEBR. DEPT. OF LABOR CHARGE ACCT. #147 11V)