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Qtr / itr. ,. <br />• .Date Assessed <br />. <br />Combined Tai Or P ayment la Lieu <br />:. .Of Groibsstiobs Dee <br />p enal <br />Penalty ~;' <br />TArnugh <br />]2/11/2014 <br />Subtotal <br />1i2012 <br />10/15/2014 <br />10 -00 <br />$0.1 I $48.38 <br />$ 48.38 <br />. 2i2012 <br />10/15/2014 <br />... --- ; :.-;: • ;-- .. . 10.00 <br />,.. :O.....— ...._. 1113.14 ° <br />. :.. $.188.14 <br />32012 <br />10/15,2014 <br />$0.00 <br />$25.00 110753 <br />$ 132.53 <br />4/2012 <br />10/152014 <br />181.45 <br />$0.00 $37.22 <br />$ 118.67 <br />• <br />1/2013 <br />10/152014 <br />$107.11 <br />125.00 $31.16 <br />$ 163.27 <br />$ 0.00 <br />• <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$0.00 <br />10.00 <br />$ 0.00 <br />TOTAL Combined Tsui or Payment in Lieu of Contributions Doe (under thin Ilen only): <br />$ 650.99 <br />Dec,12: 2014 3:19PM NE Secretary of State — UCC <br />201407828 <br />STATE TAX LIEN o NEBRASKA DEPARTMENT OF LABOR <br />• OIuIGYNAL <br />Euployer or <br />Liable Person: Donn K Hickok <br />Address: 507 Nubia St. Cairo NE 68824 <br />NDOL Serial No.: LAB- 0220 -2014 To be Bled with the Remoter of Deeds is the following Counties: <br />Hell I ! <br />This Redo Tax Lim is issued f o r unpaid combined sexes ( N e b . R e v . S an t 1148657 and 46.664) or p ima in lieu of oontrlbation3 (Neb. Res. Sem 54$- 660.01) pursuant t4 <br />the'Unitam &me Tax Lien Registration & Enticement At (Neb. Rev. S4at 177-3901, et aeq). Notice is given that eonbieed tame* or payments io lieu of ooatnirntians, <br />interest (computed at 1';S% pm month), and penalties are due from rids employer or.peraon and remain unpaid• alter demand These combined taxes or payments in Has of. <br />contributions consdlutee lien fix any and all pawnl property end reg property ie the county/counties named, belong to the cmploxer or person. whether now mimed or. <br />hacatter acquired. . <br />1 certify that the Nebraska Department of Labor has complied with the Employment Seemrity Law of the State of Nebraska in the <br />determination of the amount doe, and the employer or person has failed to pay the *moist due after demand. <br />JOHN 11. ALBIN <br />Acting Commissioner of Labor <br />_ <br />f.06`Jig(44--'(— <br />Date: December 12, 2014 <br />T:1D0CU1EN151FORMS\LieosIOrighal liea.doex <br />RETURN FILED COPIES TO Nebr. Dept. of Labor - LEGAL <br />P.O. Box 9461 <br />Lincoln, NE 6850! -4* <br />THOMAS A. UKINSSI, Legal Counsel <br />KATIE S. TIHJRBER, I.eg:d Counsel <br />No. 8167 P. 2 <br />N E Els or *rare John N e.!. - ACC SW <br />II,I <br />9914743979 -3 Pas, 1 <br />HICKOK 0QII4 K <br />Filed- 12/12/2614 42:62 PH <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 />NEBR. DEPT. OR LABOR <br />CHARGE ACCT. #14765 <br />