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08/10/2001 15:30 FAX 14024714429 <br />0)) <br />NEBRASKA UCC <br />200105071 <br />[f7.1002/ 00 <br />NDOL Office ofLegal Counsel <br />STATE TAX LIEN • NEBRASKA DEPARTMENT OF LABOR P.O. Box 94600 <br />Lincoln, NE 68509 -4600 <br />X ORIGINAL . Telephone - (402) 471 -9912 <br />FAX - 4Q2 471 -9917 <br />Employer Name: TRI Nebraska LLC d!b(a Golden C <br />.._ ...........................-...................................»...................................orral .............................. .................. . ........................................ ....................... <br />Address: c/o Tri Golden Management LLC 2435 N Diers Avenue Grand Island NE 68803 <br />NDOL Serial No.: ;.AB- 0133 -2001 To be filed with the Register of Deeds In the following Counties: <br />...• ....................................................................................................................... .................I............. , <br />-NDOL Employer Acet. No.: 0270462005 Hall <br />: <br />... ..............................5 <br />................................................................................................... ............................... ........................ ..................... ............................................... .. <br />Federal ID No. / SSA No.: 91- 1773485 i <br />This State Tax Lien is issued for unpaid combined taxes (Neb. Rev. Stm. §48 -657) or payments in lieu of contributions (Neb. Rev. Stat, §48- 660.01) pursuant <br />to the Uniform State Talc Lien Registration & Enforcement Act (Neb. Rev. Star. §77 -3901, et seg.). Notice is given that combined taxes or payments in lieu <br />of contributions, interest (computed at 1.5 %per month), and penalties are due from this employer and remain unpaid after demand. These combined taxes <br />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 <br />employer, whether now owned or hereafter acquired. <br />Combined Tax or <br />Qtr. / Yr. Date Assessed Payment In Lieu Of Contributions Due 1 Penalty Interest i Subtotal <br />4/2000 July 24, 2001 $ 2,869.34 S 0.00 $ 246.14 i S 3,115.48 <br />................................ ...................................... ................................................................................... ........................ .............. <.................................. }.................................. <br />.... <br />1/2001 ': July 24, 2001 $ 3,233.90 $ 0.00 I S 135.52 i S 3:3,69.42 <br />: ................................... ............................... ........... ............................... - ................ a............................ .... ........................... ........................... <br />' $ 0.00 <br />... ............................... i................. . .................... {............. ........... .................................... ............................................................................................... i......... ....... ......,................ <br />$ 0.00 <br />..... ............ ................... ;-..................................... i................................... , ................................I............................................................................... ........ ;...................... ................. <br />' $ 0.00 <br />..... ............................... j............... I...................... i............ .......... i.. ............................... a................................. i....... ............................... <br />S 0.00 <br />. ..................... t.........._................. .........�..................... .......................................................... t......................................... ..............................� 11.1/0 <br />i i i <br />$ 0.00 <br />l...................... <br />$ <br />0.00 <br />..................................... .. ................................ a............................................................. .................... 8.. ............................... ' <br />$ 0.00 <br />TOTAL Combined Tax or Payment in Lieu or Contributions Due (under this lien only): $ 6,484.90 <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 railed to pay the amount due afteridemand. <br />FERNANDO LECUON <br />Commission of La <br />Date: August 10, 2001 B <br />H H. BIN ter- THOMAS A. UKINSKI <br />ncy Legal Counsel Legal Counsel <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor- LEGAL <br />P.O. Box 94690 <br />Lincoln, NE 68309 -4600 <br />- — - <br />a <br />NEBR. DEPT. OF LA (iZ' <br />CHARGE ACCT. 914765 <br />