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5. 2515 2:25FM NE Secretary of State — UCC <br />STATE TAX LIEN o NEBRASKA DEPARTMENT OF LABOR <br />• ORIGINAL <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 />Employer or <br />Liable Person: Robert F Blakemore <br />Address: 2422 W 18t Street Grand Island NE 68803 <br />NDOL Serial No.: ; LAB- 0161 -2015 <br />NDOL Acct. No.: 0340459000 <br />Federal ID No. / SSA No.: i xxx xx -2602 <br />Qtr. / Yr. <br />4/2013 <br />Date: August 5, 2015 <br />Date Assessed <br />2/2013 1 7/10/2015 <br />3/2013 7/10/2015 <br />7/10/2015 <br />201505319 <br />Combined Tax Or Payment In Lieu <br />Of Contributions Due <br />RETURN FILED COPIES TO:. Nebr. Dept. of Labor - LEGAL <br />P.O. Box 94600 <br />Lincoln, NE 68509 -4600 <br />To be filed with the Register of Deeds in the following Counties: <br />Hall <br />By: <br />e{ Siete l Joh. R e.le - UCC 5TH <br />� <br />9915758077 -2 Pgs: 1 <br />BLRKE1tiORE ROBERT F <br />Filed! 08/51612016 01;49 PSI <br />E 5 e� <br />Penalty <br />E <br />This State Tax Lien is issued for unpaid combined taxes (Neb. Rev. Star. § 08 -657 and 48 -664) or payments in lieu of contributions (Neb. Rev. Stat. 148- 660.01) pursuant to <br />the Uniform State Tax Lien Registration & Enforcement Act (Web. Rev. Star. §77 -3901, et seq.). Notice is given that combined tuxes or payments in lieu of contributions, <br />interest (computed at 1.5%o per month), and penalties are due from this employer or person and remain unpaid after demand. These combined taxes or payments in lieu of <br />contributions constitute a lien 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 />$603.97 j $36.91 1 $270.86 $ 911.74 <br />$953.$8 r $52.36 ! $297.21 1— $1,303.45 <br />$517.21 ` $31.31 = $137.69 $ 68621 <br />i <br />$ 0.00 <br />' . 21 G4 F. 3/7 <br />Interest <br />Through <br />7/25/2015 <br />THOMAS A. UKINSKI, Legal Counsel <br />T; \DOCUMENTSIFORMSLLiens\Original licn.docx KATIE S. THURBER, Legal Counsel <br />Subtotal <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />3 , <br />: ! 8 0.00 <br />� $ 0.00 <br />1 i 1 <br />$ 0.00 <br />$0.00 <br />TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): <br />I $2,901.40 <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 H. ALBIN <br />Commissioner of Labor <br />NEBR. DEPT. OF LABOR <br />CHARGE ACCT. 4147654/ <br />