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Qtr. / Yr. <br />Date Assessed <br />Combined Tax Or Pay In Lieu <br />Of Contributions Due <br />Penalty <br />Interest <br />Through <br />9/4/2014 <br />Subtotal <br />1/2011 <br />8/20/2014 $0,00 <br />$25.00 <br />$100.19 i <br />$ 125.19 <br />3/2011 <br />8/20/2014 80.00 1 <br />$0.00 <br />$70.13 <br />$ 7013 <br />4/2011 <br />8/20/2014 80.00 <br />$0.00 <br />8111.79 1 <br />$ 111.79 <br />112012 <br />8/20/2014 i $315.79 <br />$0.00 <br />8384.83 <br />$ 700.62 <br />2/2012 <br />812012014 1 8751.36 <br />80.00 <br />$283.37 <br />81,034.73 <br />3/2012 <br />8/20/2014 j $504.41 <br />$0.00 <br />8167.36 <br />$ 671.77 <br />4/2012 <br />8/20/2014 j 886.30 r <br />825.00 1 <br />824.72 1 <br />$136.42 <br />112013 <br />8/20/2014 1 8158.17 <br />$0.00 ! <br />838.37 <br />$ 196.54 <br />2/2013 <br />8/20/2014 { 8107.02 <br />825.00 <br />$ ..1 <br />$ 153.12 <br />3/2013 <br />8/20/2014 $143.32 1 <br />$25.00 <br />821.76 <br />i . 8 190.08 <br />412013 <br />8/20/2014 i ' $80.90 <br />80.00 <br />88.61 <br />I $ 89.51 <br />1/2014 <br />8/20/2014 816.96: <br />$8.04 • <br />81.06 <br />$ 26.06 <br />TOTAL Combined Tax or Payment in Lieu of Contributions Due (under tki9 Rem only): <br />$3,505.56 <br />Sep,19, 2014 3,03PM NE Secretary of State - UCC <br />STATE TAX LIEN d NEBRASKA DEPARTMENT OP LABOR <br />• ORIGINAL <br />Employer or <br />Liable Person: Kimberly A. Wiseman <br />Address: 103 Beachwood Drive Grand Island NE 68803 <br />NDOL Serial No.: LAB- 0178 -2014 To be fled with the Register of Deeds im tite following Counties; <br />NDOL Acct. No.: 1 0314836005 Hall 1 <br />Federal ID No. / SSA No.: ! xxx -xx -4498 _ l <br />This State Tax Lion is issued for unpaid combined taxes (Web. Rev. Sao. 3148.657 aid 48.664) or payrnor$s in lieu of contributions (Neb Rev. Smr. 348- 660.01) pursuant to <br />the Uniform State Tax lien Registration & Enforcement Act (Neb. Rev. Slat. 377 -3901, es seq.). Notice is givan that combined taxes or payments io lieu of contributions, <br />Interest (computed at 1.5% per Month), and penalties are due from this employer or person and remain unpaid after demand. The combined taxes or payments in lieu of <br />contributions constitute a In for any and all personal propaty and real property in the county /counties nand, belonging to the employer or person, whether now owned or <br />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 />JOHN IL ALBIN <br />Acting Commissioner of Labor <br />Date: September 19, 2014 <br />T: IDOCUMENTSIFORMSti.ienstOriginal liet,docx <br />201405 <br />Ltecain, NE 68504600 <br />THOMAS A. UKTNSKI, Legal Counsel <br />KATIE S. THURBER, Legal Counsel <br />No.6754 P. 3 <br />WE !4e of 54.4* John R Cal. <br />- u[c Sri <br />I 1 1111 �I'. <br />991 4742153 <br />WISEtlpd KIMERLY A. <br />Pas: 1 <br />Plied! 9 '19r2014 18,37 nu <br />41a4/1,6-e-4_, <br />NDOL Office of Legal Counsel <br />P.O. Box 94600 <br />Lincoln, NE 68509 -4600 <br />Telephone - (402) 471 -9912 <br />PAX - (402) 471-9917 <br />RETURN FILED COPIES TO Nebr. Dept. of Labor - LEGAL NEBR. DEPT. OF LABOR <br />P.O. Bon 94400 CHARGE ACCT. #14765 <br />