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Qtr. / Yr. <br />Date Assessed <br />Combined Tax Or Payment In Lien <br />Of Contributions Dore <br />Penalty <br />Interest <br />Through <br />4/1/2015 <br />Subtotal <br />2/2011 <br />3117/2015 <br />$389.70 <br />$25.00 <br />$257.44 <br />$ 672.14 <br />3/2011 <br />3/17/2015 <br />$389.70 <br />$25.00 <br />3239.77 <br />$ 654.47 <br />4/2011 <br />3/17/2015 <br />30.00 <br />325.00 <br />$0.00 <br />L $ 25,00 <br />1/2012 <br />3/17/2015 <br />I $292.05 <br />325.00 <br />S153.48 <br />$ 470.53 <br />2/2012 <br />3/17/2015 <br />$292.05 <br />$25.00 <br />$140.24 <br />$ 457.29 <br />3/2012 <br />3/1720I5 <br />30.00 <br />$25.00 <br />$0.00 <br />$ 25.00 <br />4/2012 <br />3/17/2015 <br />30.00 <br />325.00 <br />30.00 <br />$ 25.00 <br />1/2013 <br />3)17/2015 <br />3243.00 <br />$25.00 <br />$113.98 <br />$ 351.98 <br />2/2013 <br />3/17/2015 1 <br />3243.00 <br />325.00 <br />572.96 <br />S 340.96 <br />3/2013 <br />3/17/2015 <br />30.00 <br />$25.00 <br />$0.00 <br />$ 25.00 <br />4/2013 <br />3/17/2015 <br />30.00 <br />325.00 <br />30.00 <br />$ 25.00 <br />1/2014 1 <br />3/17/2015 <br />3351.00 <br />325.00 <br />358.14 <br />$ 43414 <br />TOTAL Combined Tarr or Payment in Lien of Contributions Due (coder this lieu only): <br />33,506.51 <br />N ORIGINAL <br />Dote: April 7, 2015 <br />2015 3:08PM NE Secretary of State - <br />Employer or <br />Liable Person: <br />Address: <br />NDOL Serial No.: <br />L Acct. No.: <br />TADOC1.11vIENTSTORMLiensIOrigiaal 1ien.doex <br />Lincoln, NR 49509.4600 <br />201502149 <br />STATE TAX LIEN n NEBRASKA, DEPARTMENT OF LABOR <br />By <br />HO MA5 A. UIINSK1, Legal Counsel <br />KATIE S. TIMBER, Legal Counsel <br />„, O. 0154 P, 2 <br />'nn 11 i.f e - • ITL <br />� <br />tea: ; <br />a71st7 <br />Mg! 29;5 Yt :41 p}� <br />?IDOL Office of Legal Counsel <br />P.O. Fox 94600 <br />Lincoln, NE 68509 -4600 <br />Telephone - (402) 471.9912 <br />FAX - (402) 471 -9917 <br />Wendel G. Fettig <br />1004 Vme St. Grand Island NE 68801 _ <br />LAB-0063-2015 To be filed with the Register of Deeds in the foBowisg Counties; <br />0363131006 Hall 1 <br />1 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 ameaut due after demand. <br />JOHN $ ALBIN <br />Con nor of Labor <br />Federal YD No. / SSA No.: Lox <br />This Stab: Tax Lien is issued far unpaid combined taxes (Neb. Rev. Slat. §$49.657 and 46.664) or payments in lieu of contolotirs{s (Neb. Rev. as. §4e- 60.01) pucandrd to <br />the Uniform State Tax Lien Registration A &fo cemeat Act (Mb. Rev. Star. 377 -3901, et any.). Notice is given that combined tanteaa or payments in gnu of contributions, <br />interest (cao�uad at 1.534 per math), end penalties ere due from this employer or person and remain unpaid after demand. Thane combined tears: ar payments in lieu of <br />contributions constitute a Han for any and all personal property and real property in the mum/counties named, belonging to the employer or poison, whether now owned or <br />herca4sr acquired. <br />RETURN URN PILED COPIES TO Nebr. Dept. of Labor - LEGAL 11TE)BR. DEPT. OF I�ABC]t <br />P.O. gas 91611 CHARGE ACCT. /#14765 <br />