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_ 06/21/2001 16:51 FAX 14024714429 NEBRASKA UCC _ 0 002/004
<br />� � � III�N ll1�l 11111 11111 l[1�� 11141 1111111
<br />"RS MEBRRSKfi LLC P98 I
<br />Fitad: D6r2�r'J.o01 03 -0) PR
<br />200106173
<br />NDOL Legal Division
<br />STATE TAX LIEN • NEBRASKA DEPARTMENT OF LABOR P.O. Box 94600
<br />Lincoln, NE 68509 -4600
<br />X OlUGmaL Telephone - (402) 471 -9912
<br />FAX - 402 471 -9917
<br />Employer Name: Tri Nebraska LLC d/bh� Golden Corral
<br />......................... ..... .... ... ...................... . ........... .......... ................................................................ . ............
<br />................................,................................. ...............................
<br />Address: 2435 N. Diers Avenue Grand Island NE 68803
<br />NDOL Serial No.: LAB- 0091 -2001
<br />NDOL Employer Acct No.: 0270462005
<br />. ..................... . ....................... . ............................ .. ........... I................
<br />Federal ID No. I SSA No,: 91- 1773485
<br />To be filed with the Register of Deeds in the fallowing Counties:
<br />Hall
<br />This State Tax Lien is issued for unpaid combined t txes (Nab. Rev. Stat. §48- 657) or payments in lieu of contributions (Neb. P.ev. Stat. §48- 660.01) pursuant
<br />to 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
<br />of contributions, interest (computed at 1.5% per mixtth), and penalties are due from this employer and remain unpaid after demand, These combined taxes
<br />or payments in lieu of contributions constitute a Fen for any and all personal property and real property in the county /counties named, belonging to the
<br />employer, whether now owned or hereafter acquirt:d.
<br />Combined Tax or
<br />Qtr. / Yr. Date Assessed Payment In Lieu Of Contributions Due Interest Penalty I Subtotal
<br />2/1998
<br />Nov. 28, 2000 S
<br />0.00
<br />S
<br />3,822.23
<br />$
<br />0.00
<br />$
<br />3,822.23
<br />3/1998 Nov. 28, 2000 $
<br />0.00
<br />S
<br />2,499.31
<br />$
<br />0.00
<br />i $
<br />2,499 -31
<br />................................
<br />.:.......................... ............ ............. ....................................................
<br />. .............. ......
<br />�...................
<br />...............
<br /><.....................
<br />,............ a........ .....,.........................
<br />211999
<br />Nov. 28, 2000 S
<br />3,604.34
<br />$
<br />863.59
<br />$
<br />0:00.
<br />$
<br />4,467.93
<br />............................... i.................... .................:............, ................... ...............................
<br />3/1999 Nov. 28, 2000 $
<br />3,514.55
<br />$
<br />682.67
<br />; $
<br />0.00
<br />i S
<br />4,197.22
<br />...... ...............................
<br />a...................................... r.......................................................,....................,.........-:...
<br />..................-
<br />............
<br />i..................................:........
<br />...............................
<br />4x'1999
<br />Nov; 28, 2000 1 $
<br />2,005.78
<br />i S
<br />i....................
<br />298.63
<br />S
<br />n...........
<br />0.00
<br />S
<br />a
<br />2,304.41
<br />I .............. ,
<br />....... ........................... ... :. ................. ...............................
<br />1x000 Nov, 28, 2000 $
<br />_.... ....... ..... .....
<br />6 070.58
<br />i $
<br />. .............
<br />634.47
<br />.......
<br />$
<br />..-,...........
<br />0.00
<br />.......................
<br />$
<br />6. "03.05
<br />2/2000
<br />Nov. 28, 2000 $ 4,391.39
<br />i $
<br />259.79
<br />$
<br />0.00
<br />$
<br />4,651.18
<br />. ..............................
<br />3/2000
<br />..... ....... .. .............................. ,................. .....::................. ..............................................
<br />Nov. 28, 2000 '•. $
<br />4,476.43
<br />a.....................
<br />$
<br />.............
<br />61.79
<br />i...............................
<br />$
<br />...,...........................
<br />0.00 $
<br />�...........
<br />4,538.22
<br />.....................................
<br />i...........,.......................... 4.......................,....,....................,..... ...............................
<br />i... .................I.............
<br />i......... .........................
<br />:...-- .. ..........................,...,
<br />$
<br />0.00
<br />........ ..............................
<br />i........... . .............. , ............ ...... .... ............. ................... .............. ....., .........................
<br />a... ...............................
<br />i........................... .......l...........................
<br />i $
<br />............
<br />0.00
<br />TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): S 33,185.55
<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 has Called to pay the amount due after demagd.
<br />FERiIN
<br />Date June 21, 2001 By:
<br />RETURN FILED COPIES TO: Nebr. Dept. of Labor- LEGAL
<br />P.O. Box 94,600
<br />Lincoln, N1: 68509.4600
<br />1 BIN -ur- THOMAS A. UKINSKI
<br />Legal Counsel Legal Counsel
<br />NEBR. DEPT. OF LABOR
<br />CHARGE ACCT. #14765
<br />
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