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Ost, 11. 2018 3:02FM NE Secretary of State <br />No. 1()81 <br />NE Sec of State -,Io1n A. Gale <br />7:1:ng Document @: 1610000167-4 Pate& I <br />Debtor Name: LIFE WEST At DELLA /U.ilS, INC. <br />l=,ling bete and Time: 10/11/201[ 11:03 AM <br />201806 744 <br />STATE TAX LIEN n NEBRASKA DEPARTMENT OF LABOR <br />t• 011K: <br />NAM: Office Court t»l. <br />l:Q.; Rol .94ti01 <br />Lincoln, NE 68509-4400. <br />Telephone - (442)47L -99i2 <br />FAX - (407).471-99l3 <br />Employer or <br />Liable Person: Life quest et Belie Amis. Inc, _ <br />Address: 211 Sunny Drive, l)onipllun, NC 6811332 <br />NDOL Serial Na: LA11-0098-2018 To be flied with the Register of Deeds ha the following Counties: <br />INIDOL Acct. No.: 0343773009 Hall <br />Federal ID No.1 SSA No.: �45-3676433 .....s.......—........ <br />'Nix State 'fax Lica Is a sed far unpaid combined taxes (Nab. Raw, Star, .§4.1N- 651 and 48-(44) or payment. in 11ou U(cauributiotlI (,M-6, lama $141, §4$660.01) ruroatull to <br />flit tlnifonn State Tax Lim Regimelltl & tnl'Urcemeor Act (,Nair Rev..1?ai, 01-3901. it ivq.). t:Oticc is gkn1 tltet contbintd labs er payntc ns in Iice l c4niribtrI Uiir; <br />Immo (compliant &t .346 per montn), and penahes we ?s due frim this trepI yer Or person pard remain unpaid after demand. Thew combined votes or ptrnt <br />'aitt in ',iv of <br />eomillwtioni amount -alien forsny and nil peponsi propzny end real prop Pty in the connlykotott ct &anted, telonping to roe ompliyer Of perYon. whether now awned .r <br />Iv:ma cr arquin:d. <br />Qtr.1 Yr. <br />Dale Axed <br />Combined Tax Or P1lyntcnt In Lien <br />Of Coatribut,00s Due <br />Penalty <br />interest <br />Through <br />10,'4/29) 8 <br />Subtotal <br />01/2018 <br />_ r—_ <br />9/18/2018 <br />5676.21 <br />S4.o0 <br />$52.34 <br />S 728;55 <br />• -- <br />5 0.00 <br />----w —_,_.._. <br />! <br />S 0,00 <br />__ . <br />—. <br />S o:oo <br />S 0.00 <br />— <br />____ __. _ <br />$.o:oa <br />_ <br />5 0.00 <br />S. 0.00 <br />-- <br />50.00 <br />.._..._..._.__.,.5 0,00 <br />.5. 0.00: <br />$.0.00 <br />r <br />- <br />—1_.—._._. <br />TOTAL Combined Tax or Payment in Lien of Contributions Due (under this lien only): <br />$ 728.55. <br />I certify that the Nebraska Department of Labor has complied with the Employment Security Law of the State of,Nebrasks'ln'the <br />determination ofthe amount due, and the employer or person has fatted to pay the amount due after dcn)and..• <br />JOHN i3. ALBIN <br />Commissioner of Labor <br />Date: 10/10!2018 <br />T:IDOC UMPI 'S\F01LMSILietral0ri(eine1 Iien.doe <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL <br />P.O. nog 916110 <br />Linrota. NE 68505-1600 <br />By: <br />KATIE S- THURBER, Agency General Counsel <br />THOMAS A. UKJNSKI, Legal Counsel <br />LIBBY ELDER, Alrorney <br />NEBR. DEPT_ OF LABOR <br />CHARGE ACCT. ##14765 <br />