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■ ORIGINAL <br />Aug, 5. 2015 2:26PM <br />Qtr. / Yr. <br />Employer or <br />Liable Person: <br />Address: <br />NDOL Acct. No.: <br />3/2014 i 7110/2015 <br />4/2014 7/10/2015 <br />L <br />Date: August 5, 2015 <br />Adam Grupe <br />NDOL Serial No.: I LA13- 0158 -2015 <br />7500 Sky Park Rd. Grand Island NE 68801 <br />0362526003 <br />Federal ID No. / SSA NoTI : -xx -6453 <br />NE Secretary _t - <br />at — UCC <br />201505322 <br />RETURN FILED CONES TO: Nebr. Dept. of Labor - LEGAL <br />P.Q. Box 94600 <br />Lincoln, NE 68509 -4600 <br />STATE TAX LIEN ❑ NEBRASI(A DEPARTMENT OF LABOR <br />Date Assessed j Combined Tax Or Payment In Lien <br />Of Contributions Due <br />$0.00 <br />TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): <br />Penalty <br />NE <br />Nc.2104 P. 6/7 <br />Sae of Skeie Johi R lisle - Ure iTt. <br />9915758980 -9 Pga. t <br />GRUPE ADAM <br />Filed: 08/05/2015 01:49 PM <br />$91.80 $25.00 $12.08 <br />$25.00 $0.00 <br />NDOL Office of Legal Counsel <br />P.O. Box 94600 <br />Lincoln, NE 68509 -4600 <br />Telephone - (402) 471 -9912 <br />FAX - (402) 471 -9917 <br />To be filed with the Register of Deeds in the following Counties: <br />Hall <br />This State Tax Lien is issued for unpaid combined taxes (Neb. Rev. Stat. § Pi-651 and 48 -664) or paymerns in lieu of contributions (Neb. Rev. Star. 148- 660.01) pursuant to <br />the Uniform State Tax Lien Registration & Enforcement Act (Neb. Rev. Stat. 171 -3901, et seq.). Notice is given that combined taxes or payments in lieu of contributions. <br />interest (computed at 1.5% per month), and penalties are due from this employer or person and remain unpaid after demand. These combined taxes or payments in lieu of <br />contributions constitute a lieu for any and all personal property and real property in the county/counties named, belonging to the employer or person, whether now owned or <br />hereafter acquired. <br />Interest 1 <br />Through <br />7/25/2015 <br />Subtotal <br />$ 128.88 <br />$ 25.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 153.88 <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 />Ioi H. ALBIN <br />Commissioner of Labor <br />By: Q <br />THOMAS A. UI(INSKI, Legal Counsel <br />T:\DOCCUMBNTSWOPMSU iens\Original lien.docx KATIE S. THURBER, Legal Counsel <br />NEBR. DEPT. OF LABOR <br />CHARGE ACCT. #14765 <br />