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Qtr. / Y r. <br />Date Assessed I <br />Combined Tax Or Payment In Lieu <br />Of Contributions Due <br />Penalty <br />Interest <br />Through <br />g <br />10/25/2016 <br />Subtotal <br />01/2016 <br />9/27/2016 $2,430.66 <br />$45.01 <br />$21330 <br />$2,688.97 <br />02/2016 <br />9/27/2016 I 53,090.87 <br />$0.00 <br />$131.05 <br />.� <br />$3,221.92 <br />$ 0.00 <br />$0.00 <br />I <br />I <br />$ 0.00 <br />$ 0.00 <br />I <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): <br />$5,910.89 <br />Oct, 26. 2016 3:355M NE Secretary of State — UCC <br />Date: 10/25/2016 <br />T :1D0CUMENTSWORMS1Liens\Original lien.doex <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL <br />P.O. Box 94600 <br />Lincoln, NE 68509 -4600 <br />By: <br />201607140 <br />NE 5 <br />856) F. <br />'F <br />J/ l <br />991B7a1a71 -9 P. <br />GIGGLES ING <br />Filsd: 10/28/2016 01,48 PM <br />STATE TAX LIEN a 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: Giggles Inc <br />Address: 1409 N Webb Rd Grand Island NE 68803 <br />NDOL Serial No.: I I.AB -0109 -2016 To be filed with the Register of Deeds in the following Counties: <br />NDOL Acct. No.: 0 09212 003 Hall 1 <br />Federal ID No. / SSA No.: 20- 2008886 <br />This State Tax' Lien is issued for unpaid combined taxes (Neb. Rev. Stat. §§48-657 and 48 -664) or payments in lieu of contributions (Neb. Rev. Slat. §48- 660.01) pursuant to <br />the Uniform State Tax Lien Registration & Enforcement Act (Neb. Rev. Stat. §77 -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 arc due from this employer or person and remain unpaid after demand. These combined taxes or payments in lieu of <br />contributions constitute a lion 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 />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 />KATIE S. THURBER, Agency General Counsel <br />THOMAS A. UKINSKI, Legal Counsel <br />DALE M. SHOTKOSKI, Legal Counsel <br />NEBR. DEPT, OF LABOR <br />CHARGE ACCT. #14765 <br />�� C <br />