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07/22/2005 09:59 FAX 1402 <br />pa, L�a <br />429 NEBRASKA UCC <br />200506993 <br />STATE TAX LIEN* NEBRASKA DEPARTMENT OF LABOR <br />X OWGINAL <br />141002 <br />NE Sac of Sia4a - U[[ ST{. <br />111111111 milli I 111111111111111,11 <br />9905404259 -2 Pgs: t <br />MYLOTT JACK <br />Filed: 07/21/2005 10.38 AM <br />NDOL Office of Legal Counsel <br />P.O. Box 94600 <br />Lincoln, NE 68509 -4600 <br />Telephone - (402) 471 -9912 <br />FAX - (402) 471 -9917 <br />Employer Name: Jack Mylott f/d/b /a Complete Repair Service <br />Address: 3447 N. Hwy 281 Grand Island NE 68803 <br />NDOL Serial No.: ' LAB- 0109 -2005 To be filed with the Register' of Deeds in the following Counties: <br />NDOL Employer Acet. No 0305462008 w Hall Howard _- <br />Federal ID No. / SSA No.: 74- 3122501 <br />This State Tax 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 />to the Uniform State Tax Lien Registration & Enforcement Act, (Neb. Rev. Stat. § 77 -3901, et seq.). Notice is given that combined taxes or payments in 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 takes or <br />payments in lieu of contributions constitute a lien for any and all personal p;dperty and real property in the county /counties named, belonging to the employer, <br />whether now owned or hereafter acquired. <br />Qtr. / Yr. <br />Date Assessed <br />Combined Tax Or Payment In Lieu <br />Of Contributions Due <br />Penalty <br />Interest <br />Through <br />7/13/2005 <br />6/28/2005 t <br />6/28/2005 <br />6/28/2005 <br />$455.00 <br />$455.00 <br />$45'5.00 <br />$25.00 <br />$25.00 <br />$25.00 <br />$57.20 <br />$36.56 <br />$16.60 <br />3/2004 <br />4/2004 <br />1/2005 <br />TOTAL Combined Tax or Payment in Lieu of Contributions Due (under this lien only): <br />Subtotal <br />$ 537.20 <br />$ 516.56 <br />$ 496.60 w <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />0.00 <br />$ 0.00 <br />$ 0.00 <br />$ 0.00 <br />$1,550.36 <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 1ACUONA, III f,,, ., <br />Date: July 21, 2005 _ 7 By: <br />RETURN FILED COPIES TO: Nebr. Dept. of Labor- LEGAL <br />P.O. Box 94600 <br />r,inmin. NF: 6AS09 -AMM <br />THOMAS A. UIGNSKI <br />Legal Counsel <br />NEBR DEPT. OF LABOR <br />CHARGE ACCT. #14765W <br />