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Qtr. / Yr. <br />i Date Assessed Combined Tax Or payment In Lieu <br />Of Contributions Dne <br />Penalty <br />Interest <br />Through <br />dot <br />Subtotal <br />14 / 2 I 9117/2014 I <br />$150.75 <br />$0.00 <br />$0.00 <br />$ 150.75 <br />$ 0.00 <br />1 <br />$ 0.00 <br />$ 0.00 <br />—.--1 <br />$0.00 <br />$0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />I I 1 <br />_ �_ <br />$ 0.00 <br />$ 0.00 <br />TOTAL Combined Ts* or Payment in Lien of Coatributions Due (under this lieu only): S 150.75 <br />Nov. 4, 2014 3 :42FM NE Secretary of State — UCC <br />STATE TAX LIEN o NEBRASKA DEPARTMENT OF LABOR <br />• ORIGINAL <br />Employer or <br />Liable Person: Todd 1. Van Skiver. d/b /a Johnson Cash Way Lumber <br />Address; 1314 Country Chib Drive, Hastings, NB 66901 <br />NDOL Serial No.: 1 LAB- 0202-2014 To be filed with the <br />NDOL Acct. No.: 1 0008774005 I4a11 <br />Federal ID No. / SSA No.: 1 xxx- xx-4976 _ <br />This State Tax Lim is issued for unpaid combined taxes (Neb. Rev. &at ¢§48 -657 and 48 64) or paymcnrs in lieu at cootribnums (Neb, Rev. SAIL §48- 660,01) pursuant to <br />the Uniform State Tax Lice Registration & Enforcenamt Aut (Neb, J. Slat §77-390l, er req,). Notice is given that combined tricot c paydnegts in lieu of coutribusioos, <br />Interest (computed at 1.594 per mouth), and penalties am due from this employer or person and remain unpaid after demand. ['hest combined taxes or payments in lieu of <br />contributions constitute a Den for any and all personal property and real property in the county /counties named, belonging to the employer or person, whether now owned or <br />hereafter acquired. <br />Date: November 4, 2014 <br />L:VQeneral Course hLega1117OCUMENTSlLieas\State Tax Lims1D0 0000D 000110 <br />08774 005 Slciver.doac <br />201407036 <br />By: <br />er of Deeds in the following Counties: <br />No. 7494 P. 2/8 <br />1i Ss- of SioO0 Jef. A gate - me STL <br />90 -9 Pis: 1 <br />JOHNSON S CASH LUMBER <br />6 AM <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 />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 emonlat due, and the employer or person has failed to pay the amount die after demand. <br />JOHN IL AL.BIN <br />Acting Commiasfioner of Labor <br />; <br />THOMAS A. Uf tSHI, Legal Counsel <br />KATIE S. THURBER, legal Counsel <br />RETURN FILED COPIES TO: Nebr. Dept of Labor - LEGAL MDR. DEPT. OF LABO <br />P.O. hex 94600 CHARGE ACCT. #14765 <br />Lincoln, NE 68508 -1610 <br />1 <br />