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NDOL Serial No.: <br />LAB- 0112 -2016 <br />To be filed with the Register of Deeds in the following Counties: <br />NDOL Acct. No.: <br />03 53953 007 <br />Hall <br />02/2015 <br />11/7/2016 <br />Federal 1D No. / SSA No.: <br />m -xx -5836 <br />$25.54 <br />$ 25.54 <br />03/2015 <br />Qtr. / Yr. <br />Date Assessed <br />Combined Tali Or Payment In Lieu <br />Of Contributions Due <br />Penalty <br />Interest <br />Through <br />1 1/22/2016 <br />Subtotal <br />02/2015 <br />11/7/2016 <br />$0.00 <br />$0.00 <br />$25.54 <br />$ 25.54 <br />03/2015 <br />11/7/2016 <br />$140.75 <br />$0.00 <br />$28.69 <br />$ 169.44 <br />02/2016 <br />11/7/2016 <br />$132.52 <br />$0.00 <br />$7.45 <br />$ 139.97 <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 />TOTAL Combined Tax or Payment in Lieu of Due (under this lien only): <br />$ 334.95 <br />0 <br />Dec. 13. 2016 2:58PM NE Secretary of State — UCC No, 9071 P. <br />201608857 <br />NC See el' 14efe John R Gal. - UCC 91H <br />9816783817 -9 Pas; 1 <br />BOHNRRT LORI L. <br />Filed! 12/13/2018 01 :43 PM <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; <br />Address: <br />Lori L. Bohnart <br />108 W Cedar St., Doniphan, NE 68832 <br />This State Tax Lien is issued for unpaid combined taxes (Neb. Rev. Stat. ¢ §45-657 and 48 -664) or payments in lieu of contributions (Neb. Rev. Star, 148- 660.01) pursuant in <br />the Uniform State Tax Lien Registration & Enforcement Act (Neb. Rev. Stat. 177 -3901, er 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 lien for any and all personal property and real property in the county /counties named. belonging to the employer or person. whether now owncd 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 IL ALBIN <br />Commissioner of Labor <br />Date: December 13, 2016 <br />T:\DOCUMENTSIFORMS\Liens \Original lien.docx <br />RETURN RILED COPIES TO: Nebr. Dept. of Labor - LEGAL <br />P.O. Box 94600 <br />Lincoln, NE 68509-4600 <br />B y : <br />ICA S. S. T ' ' , ' ' Agency General Counsel <br />THOMAS A. IIIONSK , Legal Counsel <br />DALE M. SHOTKOSKI, Legal Counsel <br />NEBR DEPT. OF LABOR <br />CHARGE ACCT. #147(Sr <br />