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Q tr. / Yr. Date Assessed Combined Tax Or Payment In Lieu E Of Contributions Due Penalty Interest Through 1/31/2013 Subtotal 1 2/2011 1/16/2013 { $498.93 $0.00 $135.28 $ 634.21 3/2011 1/16/2013 1/16/2013 1 $864.09 $0.00 _ $779.86 $0.00 $195.11 $1,059.20 4/2001 $140.72 $ 920.58 1/2012 _______.__ 1/16/2013 1 _____ ....... I< 1 $234.80 $0.00 $31.95 $ 266.75 $ 0.00 1 $ 0.00 $ 0.00 $ 0.00 i 1 $ 0.00 11 1 $ 0.00 E — $ 0.00 1 $ 0.00 TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): $2,880.74 02/07/2013 THU 13:58 FAX 402 471 4429 UCC SECRETARY OF STATE STATE TAX LIEN a NEBRASKA DEPARTMENT OF LABOR • ORIGINAL NDOL Office of Legal Counsel P.O. Box 94600 Lincoln, NE 68509 -4600 Telephone - (402) 471 -9912 FAX - (402) 471 -9917 Employer or Liable Person: Dana Tompkin f/d/b /a Eclipse Drafting & Construction Address: 11750 S 190 Wood River NE 68883 NDOL Serial No.: 1 LAB- 0023 -2013 NDOL Acct. No.: 1 0332044004 Federal ID No. / SSA No.: 1 81- 0572697 Date. February 7, 2013 T:\DOCUMENTS\FORMS\Liens \Original lien.docx P.O. Box 94600 Lincoln, NE 68509 -4600 20/301031 To be filed with the Register of Deeds in the following Counties: Hall Hall 0003 /003 NE Sec of Stake John A Gale - UCC ST 111111111 III 9933708258 -2 Pgs: 1 THOMPKIN DANA Filed: 02/07/2013 10:34 AM 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 Be. 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 ner Lab Bv: Agency Legal Counsel S A. UKINSKI, Legal Counsel 1 , RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL NEBR. DEPT. OF LABOR CHARGE ACCT. #14765