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Qtr. / Yr. <br />Date Assessed <br />Combined Tax Or Payment In Lieu <br />Of Contributions Due <br />Penalty <br />x <br />Interest <br />Through <br />3/7/2013 <br />Subtotal <br />3/2008 <br />2/20/2013 <br />$162.00 <br />$25.00 <br />$126.83 <br />$ 313.83 <br />4/2008 <br />2/20/2013 <br />$0.00 <br />45.00 <br />$0.00 <br />$ 25.00 <br />1/2009 <br />2/20/2013 <br />$162.00 <br />$0.00 <br />$112.37 <br />$ 274.37 <br />2/2009 <br />2/20/2013 <br />$162.00 <br />, .. $25.00 <br />$105.02 <br />$ 292.02 <br />3/2009 <br />2/20/2013 <br />$0.00 <br />'. $45.00 <br />$0.00 <br />$ 25.00 <br />2/2010 <br />2/20/2013 <br />$311.76 <br />$ <br />$146.01 <br />$ 482.77 <br />3/2010 <br />2/20/2013 <br />$311.76 <br />, $45.00 <br />$131.87 <br />$ 468.63 <br />4/2010 <br />2/20/2013 <br />$311.76 <br />-: $45.00 <br />$117.73 <br />$ 454.49 <br />1/2011 <br />2/20/2013 <br />$311.76 <br />~ 84 <br />± $45.00 <br />$104.05 <br />$89.91 <br />$ 440.81 <br />$ 426.67 <br />2/2011 <br />2/20/2013 <br />- ` - <br />$311.76 <br />3/2011 <br />2/20/2013 <br />$311.76 <br />, $25.00 <br />$45.00 <br />$75.77 <br />$61.63 <br />$ 412.53 <br />$ 398.39 <br />4/2011 <br />2/20/2013 <br />$311.76 <br />1/2012 <br />2/20/2013 <br />$233.64 <br />" 7 $25.00 <br />$35.82 <br />$ 294.46 <br />2/2012 <br />2/20/2013 <br />$233.64 <br />25.00 <br />$25.23 <br />$14.63 <br />$ 283.87 <br />$ 273.27 <br />3/2012 <br />2/20/2013 <br />$233.64 <br />5.00 <br />4/2012 <br />2/20/2013 <br />$233.64 <br />$25.00 <br />4.03 <br />$ 262.67 <br />$ 0.00 <br />TOTAL Combined Tax or Payment in <br />Lieu of Contributions Due (under this lien only): , •; <br />$5.128.78 <br />03/14/2013 THU 14:46 <br />STATE TAX LIEN ❑ NEBRASKA DEPARTMENT OF LABOR <br />■ ORIGINAL <br />Employer or <br />Liable Person: Gail D. Klingspom <br />Address: 603 Lilly St. Wood River NE 68883 -2141 <br />NDOL Serial No.: <br />NDOL Acct. No.: <br />Federal ID No. / SSA No.: <br />Date: March 14, 2013 <br />FAX 402 471 4429 UCC SECRETARY <br />LAB - 0082 -2013 <br />0319367007 <br />xxx -xx -2646 <br />T: \DOCUMENTS \FORMS \Liens\Original lien (12+gtrs).docx <br />Bv: <br />OF STATE <br />201301995 <br />Hall <br />[2002 /004 <br />9913710672 -6 Pss: 1 <br />KLINGSPORN GAIL 0. <br />Filed: 03/14/2013 09:55 AN <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 />To be filed with the Register of Deeds in the following Counties: <br />Hall <br />This State Tax Lien is issued for unpaid combined taxes Neb. Rev Stat. °r "R <br />P ( § §48 -657 and 48 -�64) gr payments in lieu of contributions (Nab. Rev. Stat. <br />§48- 660.01) pursuant to the Uniform State Tax Lien Registration & Enforcement Act (Neb. Rey. ,Scat. §77 -3901, et seq.). Notice is given that combined <br />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 <br />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 <br />county/counties named, belonging to the employer or person, whether now owned or hereafter acq uiied. ' <br />I certify that the Nebraska Department of Labor has complied with the Employm nt ecprity Law of the State of Nebraska in the <br />determination of the amount due, and the employer or person has failed to pay the arnRput due after demand. <br />CATHERINE LING <br />Commissi nor Q Liibor <br />Agency Legal Counsel <br />SKI, Legal Counsel <br />