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071'02�2003 08:00 FAX 14024714429 NEBRASKA UCC IZO02 /003 <br />200308440 <br />STATE TAX LIEN • NEBRASKA DEPARTMENT OF LABOR NDOL Office of Legal Counsel <br />P.O. Box 94600 <br />X OWGINAL Lincoln, NE 68509 -4600 <br />Telephone - (402) 471 -9912 <br />FAX - (402) 471 -9917 <br />Employer Name: Shafer Inc. <br />-----------------____ __._...----- •- •- •---- ____._ -__- ___....____..__..____...._........_...--•_ _..._._..._._....__....____.... <br />Address: 1004 No. Diers Ave. #300 Grand Island NE 68803 <br />NDOL Serial No.: LAB -0169 -2003 To be filed with the Register of Deeds in the following Counties: <br />- .._..._....� _..._........... .... <br />NDOL Employer Acct. No.: 0287735006 Hall <br />.._ .- <br />Federal ED No. /SSA No.: 91- 1847680 _ . .i i..._.____.-..__.___._....- <br />This State Tau Lien is issued for unpaid combined taxes (Neb. Rev. Stat. §48 -657) or payments in lieu of contributions (Neb. Rev. Stat. §48- 660.01) pursuant <br />tj the Uniform State Tax Lien Registration & Enforcement Act (Neb. Rev. Stat. §77 -3901, et seq.). Notice is given that combined taxes or payments is lieu of <br />contributions, interest (computed at 1.5% per month), and penalties are due from this employer and remain unpaid after demand. These combined taxes or <br />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, <br />wheiber now owned or hcreafter acquired. <br />Combined Tax Or Payment In Lieu Merest <br />Qtr. / Yr. Date Assessed Penalty Through Subtotal <br />Of Contributions Due i 06120/2003 <br />i <br />2/2002 June 5, 2003 i $2.356.71 . $83,10 i $376.44 i <br />$2,81625 <br />3/2002 June 5, 2003 $1,228.99 $87.57 $140.57 I <br />$1 ;457.13 <br />- - - - - - -- — ------ - - - - -- -- .._.L- - -- .._..._._... - -I -- - -- - -- -- - - -- --- <br />- 4/2002 June 5, 2003 ^ —^ $619.47 ! S61.33 ! $42.76 <br />•---- ._._.___... - - -- <br />$ 723.56 <br />- - -- ....;...- - -- ...._....._..._... ;_ _ ...-_...- .........._.......,..__.__. <br />�.—._,__._____._.____.._._.__..—_.._.__ _..- •- •- _- •.--- .--- ___�...___._ � <br />-__. _ <br />SS 0.00 <br />........... ... - ...... - -- - ---... r...__..._.. <br />_...._..._.__.._.._........_... <br />0.00 <br />--- .............. ..... - r... --- ......-- __.._._..._ ... - - ._...... <br />00 <br />_ <br />$ 0 <br />- - - - -- - - -_- - <br />000 <br />0,00 <br />. .. . ....... ............. <br />i <br />$ 0.00 <br />i <br />$ 0.00 <br />TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): 1 <br />$4,996.94 <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. III <br />Date: June 30, 2003 By: <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor - LEGAL <br />P.O. Box 94600 <br />Lincoln. NE 685094600 <br />OaLM&VIN -or. THOMAS A. UKINSKI <br />Legal Counsel Legal Counsel <br />NEBR. DEPT. OF LABOR <br />CHARGE ACCT. 414765 <br />V <br />