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NDOL Serial No.: LAB- 0015 -2018 To be filed with the R inter of Deeds in the followin . Counties; NDOL Acct. No,: 0288410005 Subtotal 02/2017 Federal ID No. / SSA No.: xxx -xx -8728 $0.00 $16.22 Qtr. / Yr. Date Assessed Combined Tax Or Payment Ia Lieu Of Contributions Due Penalty Interest Through 3/2/2018 Subtotal 02/2017 2/14/2018 $153.77 $0.00 $16.22 $ 169.99 03/2017 2/14/2018 $108.15 $0.00 $6.50 $ 114.65 04/2017 2/14/2018 $42.71 $0.00 $0.63 $ 43.34 $ 0.00 $ 0.00 $ 0.00 $ 0.00 8 0.00 $ 0.00 $0.00 $ 0.00 $ 0.00 TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): [ $ 327.98 Var. 7. 2513 4:16PM NE Secretary of State — UCC STATE TAX LIEN ❑ NEBRASKA DEPARTMENT OF LABOR • ORIGINAL AL Date: 3/6/2018 Employer or Liable Person: Charlene R. Rath Address: 1504 W Ave_ Grand Island, NE 68801 T ;\DOCUMENTSWORMS1Liens1Originel lien.docx RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL P.O, Box 94600 Lincoln, NE 68509-4600 201801408 By: No. 3625 P. 2 ME 51tc of W, B Gar. . 1 R918867275.e Pas: i Filed M 31e7/2016 R. PM UCC 51L NDOL Office of Legal Counsel P.O. Box 94600 Lincoln, NE 68509 -4600 Telephone - (402) 471 -9912 FAX - (402) 471 -9917 This State Tax Lien is issued for unpaid combined taxes (Neb. Rev. Stat. §148 -657 and 48 -664) or payments in lieu of contributions (Nub, Rev. Stat. §48- 660.01) pursuant to the Uniform State Tax Lien Registration & Enforcement Act (Neb. Rev. Slat. §77-3901, at seg.). Notice is given that combined taxes or payments in lieu of contributions, interest (computed at 1.5% per month), and penalties are due from this employer or person and remain unpaid after demand. Those combined taxes or payments in lieu of 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 owned or hereafter acquired. I certify that the Nebraska Department of Labor has complied with the Employment Security Law of the State of Nebraska in the determination of the amount due, and the employer or person has failed to pay the amount due after demand. JOHN H. ALBIN Commissioner of Labor KA1IE S. : ER, Agency General Counsel THOMAS A. IJKINSKI, Legal Counsel LIBBY ELDER, Attorney NEBR. DEPT. OF LABOR CHARGE ACCT. #14765 .