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C9g <br />Oct, 26. 2016 3:35PM •NE Secretary cf State — UCC <br />STATE TAX LIEN ❑ NEBRASKA DEPARTMENT OF LABOR <br />■ TERMINATION <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 Pelson: Adam Gro e <br />Address: 7500 Sky Park Rd, Grand Island NE 68801 <br />NDOL Acct. No.: 03 62526 003 <br />Federal ID No. / SSA No.: xxx -xx -6453 <br />This TERMINATION serves to remove the lien described below and the priority of the Nebraska Department of Labor on the <br />affected property of this employer or person. This Termination is filed pursuant to Neb, Rev. Stat. § §48 -657, 48- 660.01, 48-664, <br />and the Uniform State Tax Lien Registration & Enforcement Act (Neb. Rev, Stat. §77 -3901, et seq.). <br />I X I FULL Termination <br />Property description (ONLY if PARTIAL Release): <br />n/a <br />bate: October 25, 2016 <br />T:\ DOCTJMENTS WORMS\Liens \Termination.docx <br />LIEN TO BE TERMINATED: <br />I PARTIAL Release <br />I certify that the Nebraska Department of Labor has complied with the Employment Security Law of the State of Nebraska <br />in the determination of the amount due, and the employer or person has failed to pay the amount due after demand. <br />By: <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL <br />P.O. Box 94600 <br />Lincoln, NE 68509 -4600 <br />201607141 <br />JOHN H. ALBIN <br />Commissioner of Labor <br />NDOL Serial No.: LAB -0158 -2015 <br />State Tax LienDocument No.: 9915758980 -9 <br />County: Hall <br />County Document Filing No.: 0815005322 <br />Other Filing Information: Orig. Filed Co 08/05/2015 Q <br />2:23 PM # 201505322 <br />i E Sec of 5k ale Johr. P 5.1+ - OCC 1139 <br />KATIE S. THURBER, Agency General Counsel <br />THOMAS A. UKINSKI, Legal Counsel <br />DALE M. SHOTKOSKI, Legal Counsel <br />N0, 8560 P. 4;'5 <br />9916781872 -1 PBS: <br />GRUPE ADAM <br />F11td: 10/26/2016 01:48 PM <br />NEBR. DEPT. OF LABOR <br />CHARGE ACCT. #14765 <br />M C <br />