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10/04/2001 14:18 FAX 14024714429 NEBRASKA UCC 9002/002 <br />200110050 <br />STATE TAX LIEN • NEBRASKA DEPARTMENT OF LABOR <br />X ORIGINAL <br />nr rre e� iiN■ - YCC r "L <br />I <br />9901170242 -6 <br />Tat NEBlipiltp LLC <br />F1 ad: 70/04/2001 10:13 AM <br />NDOL Office ofLegal Counsel <br />P.O. Box 94600 <br />Lincoln, NE 68509 -4600 <br />Telephone - (402) 471 -9912 <br />FAX - (402) 471 -9917 <br />Employer Name: Tri Nebraska LLC d/b /a Golden Corral - <br />.................................................. ,..........,.. ............................... .._..............---........................ .........,..................... . <br />Address: c/o Tri Golden Mgmt. LLC 2435 N. Diers Avenue Grand Island NE 68903 <br />NDOL Serial No.: LAB - 0189 -2001 To be filed with the Register of Deeds in the following Counties: <br />.................................................................................................................................................................................................................................................. ............................... <br />NDOL Employer Acct. No.: 0270462005 Hall I Buffalo i <br />.......... . .................................... :............................................... ................................................. <br />Federal ID No. I SSA No.: 91- 1773485 <br />This State Tax Lien is issued forunpaid combined taxes (Neb. Rev. Star §48 -657) orpsyments in lieu of contributions (Neb. Rev. Star. §48- 660.01) pursuant <br />to the Uniform State Tax Lien Registration & Enforcement Act (Neb. Rev. Star. ¢77 -3901, et seq.). Notice is given that combined taxes or payments in lieu <br />of contributions, interest (computed at 1.5% per month), aid penalties are due from this employer and remain unpaid aftcr 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 i Payment In Lieu Of Contributions Due Penalty Interest Subtotal <br />22001 Sept. It. 2001 $ 1,000.00 $ 66.67 ; $ 20.71 $ 1,0$7.38 <br />.................. •......... <br />_..................... .............................................................,................ 4................................. .;................- .- .......... .. 4.......................... <br />s s 0.00 <br />..................................... .............. . ....................... a............................................ ........ ....- ........................, . 1.................................... ................._............. ................... 0.00.... <br />.. ............................... <br />i ......................................«-•...............................-••••...............................................{....................................... .......................................................... ........... <br />..... ............................... <br />I $ 0.00 <br />i $ 0.00 <br />$ 0.00 <br />t.... ......:.................................. 4..................................;........ ............................... <br />$ 0.00 <br />...... ............................... i...................... «. .............4................. ..... ....... ..... .................................. '.................. 4............................... .................................... . 1..................... .................. <br />: $ 0.00 <br />...... ............................... ...................................... ..... .............................t. . ............................... i... <br />7 ....................... $ 0.00 <br />i <br />TOTAL Combined Tax or Payment In Lieu of Contributions Due (under this lien only): $ 1,087.38 <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 failed to pay the amount due after demand. <br />FERNANDO LECUONA, Ill <br />Commissioner of Labor <br />Date: October 4, 2001 By; <br />JOHN H. ALBIN -or- THOMAS A. UKINSKI <br />Agency Legal Counsel Legal Counsel <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor- LEGAL <br />P.O. Box 94600 <br />Lincoln, NE 68509 -4600 <br />NEBR. DEPT. OF LABOR <br />CHARGE ACCT. #14765 <br />