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Qtr. / Yr. <br />Date Assessed <br />Interest <br />Combined Tax Or Payment In Lieu Penalty j Through <br />Of Contributions Due <br />1/30/2013 <br />Subtotal <br />1/2012 <br />1/15/13 <br />$200.56 i $0.00 $27.19 <br />$ 227.75 <br />$ 0.00 <br />$ 0.00 <br />____i_ <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />1--- <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />___ <br />$ 0.00 <br />$ 0.00 <br />TOTAL Combined Tax or Payment in <br />Lieu of Contributions Due (under this lien only): <br />$ 227.75 <br />02/07/2013 THU 13:58 FAX 402 471 4429 UCC SECRETARY OF STATE <br />2 01301032 <br />NE Sec of State John A Gale - UCC STL <br />11111 11 1111 <br />9913708157 -0 pgs <br />MYERS GERALD D. <br />Filed: 02/07/2013 10:34 AM <br />yyy <br />Hall 2002/003 <br />STATE TAX LIEN o 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: Gerald D. Myers f/d/b /a Bubba Jers Family Diner <br />Address: 2028 East Highway 30 Grand Island NE 68801 <br />NDOL Serial No.: <br />NDOL Acct. No.: <br />Federal ID No. / SSA No.: <br />LAB -0024 -2013 <br />0343170004 <br />45- 3667412/xxx -2482 <br />To be filed with the Register of Deeds in the following Counties: <br />Hall a 1 <br />This State Tax Lien is issued for unpa d combined taxes (Neb. Rev. Stat. 1148 -657 and 48 -664) or payments in lieu of contributions (Neb. Rev. Stat. 148- 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 taxes 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 N ebraska 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 />Commissio .•J.�r <br />Date: February 7, 2013 <br />T: \DOCUMENTS\FORMS\Liens\Original lien.docx <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL <br />P.O. Box 94600 <br />Lincoln, NE 68509 -4600 <br />By: <br />IN, Agency Legal Counsel <br />H AS A. UKINSKI, Legal Counsel <br />NEBR. DEPT. OF LABOR <br />CHARGE ACCT. #14765 <br />